Provider Demographics
NPI:1083124135
Name:KELLY, KAIDDEN (DMSC, PA-C)
Entity Type:Individual
Prefix:DR
First Name:KAIDDEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62-100 KAUNAOA DR
Mailing Address - Street 2:KOHALA COAST URGENT CARE
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-9749
Mailing Address - Country:US
Mailing Address - Phone:808-880-3321
Mailing Address - Fax:808-475-0061
Practice Address - Street 1:62-100 KAUNAOA DR
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-9749
Practice Address - Country:US
Practice Address - Phone:808-880-3321
Practice Address - Fax:808-475-0061
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant