Provider Demographics
NPI:1275886467
Name:LOAN, KERRY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:MARIE
Last Name:LOAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:MARIE
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-4401
Mailing Address - Country:US
Mailing Address - Phone:603-692-2228
Mailing Address - Fax:
Practice Address - Street 1:21 CLARK WAY
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-4401
Practice Address - Country:US
Practice Address - Phone:603-692-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4472363AM0700X
NH1050363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical