Provider Demographics
NPI:1003899493
Name:KELLOGG, KEVIN RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-624-2313
Mailing Address - Fax:
Practice Address - Street 1:16528 DESMET CT
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3522
Practice Address - Country:US
Practice Address - Phone:509-944-8920
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005240363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0223708OtherLABOR & INDUSTRIES
WA8489171Medicaid
8869632OtherMEDICARE