Provider Demographics
NPI:1043306848
Name:VALETTI, KELLY KUCHAR (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KUCHAR
Last Name:VALETTI
Suffix:
Gender:F
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:P. O. BOX 8676
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29604-8676
Mailing Address - Country:US
Mailing Address - Phone:864-232-7338
Mailing Address - Fax:864-239-6645
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE B200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-232-7338
Practice Address - Fax:864-239-6645
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA601363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0409PAMedicaid
SCS96730Medicare UPIN
SCS967301874Medicare PIN