Provider Demographics
NPI:1164633566
Name:WARGO, KELLI A (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:WARGO
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 1:501 E 74TH ST APT 7B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA052944363A00000X
NY011507-1363A00000X
PAMA052944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA322562Medicare UPIN