Provider Demographics
NPI:1225061435
Name:FATHEREE, KELLI ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELAINE
Last Name:FATHEREE
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 1:7460 WARREN PKWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:972-668-5400
Mailing Address - Fax:
Practice Address - Street 1:7460 WARREN PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4169
Practice Address - Country:US
Practice Address - Phone:972-668-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200105RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01226202OtherRAILROAD PTAN
LA1040312Medicaid
LAQ61565Medicare UPIN