Provider Demographics
NPI:1417926684
Name:EGLINGER, KELLI (PA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:EGLINGER
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:WV
Mailing Address - Zip Code:26801-0097
Mailing Address - Country:US
Mailing Address - Phone:304-897-5915
Mailing Address - Fax:304-897-8472
Practice Address - Street 1:17978 SR 55
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:WV
Practice Address - Zip Code:26801
Practice Address - Country:US
Practice Address - Phone:304-897-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P05180Medicare UPIN
00W333B04Medicare ID - Type Unspecified