Provider Demographics
NPI:1336138627
Name:PETERS, KELLI V (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:V
Last Name:PETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:318 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1705
Practice Address - Country:US
Practice Address - Phone:856-547-6000
Practice Address - Fax:856-546-3189
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-04-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMP000023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356Medicare Oscar/Certification
NJS64982Medicare UPIN
NJ20385SK3Medicare ID - Type Unspecified