Provider Demographics
NPI:1225110224
Name:KEHL, MARY CATHERINE (PA C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:KEHL
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 1:410 N MALACATE ST
Mailing Address - Street 2:
Mailing Address - City:AJO
Mailing Address - State:AZ
Mailing Address - Zip Code:85321-2254
Mailing Address - Country:US
Mailing Address - Phone:520-387-5651
Mailing Address - Fax:520-387-6036
Practice Address - Street 1:410 N MALACATE ST
Practice Address - Street 2:
Practice Address - City:AJO
Practice Address - State:AZ
Practice Address - Zip Code:85321-2254
Practice Address - Country:US
Practice Address - Phone:520-387-5651
Practice Address - Fax:520-387-6036
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ890518OtherAHCCCS
AZ890518-02Medicaid
AZ890518-02Medicaid
Z107389Medicare ID - Type Unspecified