Provider Demographics
NPI:1407956980
Name:HEKTOR, KELLI AB (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:AB
Last Name:HEKTOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:A
Other - Last Name:BENNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2343 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1092
Mailing Address - Country:US
Mailing Address - Phone:607-266-9100
Mailing Address - Fax:607-266-9200
Practice Address - Street 1:2343 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1092
Practice Address - Country:US
Practice Address - Phone:607-266-9100
Practice Address - Fax:607-266-9200
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02650388Medicaid
NY02650388Medicaid
NYQ43315Medicare UPIN