Provider Demographics
NPI:1316043698
Name:CHASE, KELLI A (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:CHASE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:A
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2374 E PACIFICA PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6214
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7040
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-6288
Practice Address - Fax:310-698-7054
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69298207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12237OtherPHYSICIAN LICENSE
CODR-48660OtherPHYSICIAN LICENSE
UT742025-1205OtherPHYSICIAN LICENSE
CAA69298OtherPHYSICIAN LICENSE
NY268179OtherPHYSICIAN LICENSE
ORMD184780OtherPHYSICIAN LICENSE
AZ36223OtherPHYSICIAN LICENSE
CA00A692980Medicaid
UT7420275-1205OtherPHYSICIAN LICENSE