Provider Demographics
NPI:1346234390
Name:FRIEDMAN, KELLISUE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLISUE
Middle Name:
Last Name:FRIEDMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HOLLAND WAY FL 1
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2997
Mailing Address - Country:US
Mailing Address - Phone:603-775-0000
Mailing Address - Fax:603-658-0032
Practice Address - Street 1:21 HAMPTON RD BLDG 2
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-4831
Practice Address - Country:US
Practice Address - Phone:603-775-0000
Practice Address - Fax:603-658-0032
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0414363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3083042Medicaid
NH3083042Medicaid
NHP66271Medicare UPIN
NH30333569Medicaid
NH970029320OtherRR MEDICARE
NH3083042Medicaid