Provider Demographics
NPI:1083324719
Name:PEREZ, KALEB MICHAEL (PA)
Entity Type:Individual
Prefix:MR
First Name:KALEB
Middle Name:MICHAEL
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3769 COUNTY ROAD 93
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43469-9788
Mailing Address - Country:US
Mailing Address - Phone:419-575-1271
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3908
Practice Address - Country:US
Practice Address - Phone:419-575-1271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant