Provider Demographics
NPI:1114271152
Name:PAULSON, KELLY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5310 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4706
Mailing Address - Country:US
Mailing Address - Phone:602-865-4011
Mailing Address - Fax:602-412-7475
Practice Address - Street 1:5310 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 301
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4706
Practice Address - Country:US
Practice Address - Phone:602-865-4011
Practice Address - Fax:602-412-7475
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant