Provider Demographics
NPI:1043560915
Name:PIAZZA, KELLY J (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:PIAZZA
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 1:1510 E MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4826
Mailing Address - Country:US
Mailing Address - Phone:805-928-0610
Mailing Address - Fax:805-928-0680
Practice Address - Street 1:1510 E MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4826
Practice Address - Country:US
Practice Address - Phone:805-928-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty