Provider Demographics
NPI:1073945267
Name:PITZER, KELLY M (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:PITZER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:BRUEGGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3050 MACK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5379
Mailing Address - Country:US
Mailing Address - Phone:513-924-8915
Mailing Address - Fax:513-924-8929
Practice Address - Street 1:3050 MACK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5379
Practice Address - Country:US
Practice Address - Phone:513-924-8915
Practice Address - Fax:513-924-8929
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091479Medicaid
OHH189930Medicare PIN