Provider Demographics
NPI:1144221508
Name:TROGDON, KELLY J (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:TROGDON
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 1:360 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5612
Mailing Address - Country:US
Mailing Address - Phone:336-625-8410
Mailing Address - Fax:336-625-8405
Practice Address - Street 1:360 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5612
Practice Address - Country:US
Practice Address - Phone:336-625-8410
Practice Address - Fax:336-625-8405
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103601363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2757883AMedicare ID - Type Unspecified
NCP80906Medicare UPIN