Provider Demographics
NPI:1346328846
Name:ASAN, KELLY P (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:ASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:600 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-569-7408
Practice Address - Fax:209-491-7587
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA93449207L00000X
CODR.0052438207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A934490Medicare ID - Type Unspecified