Provider Demographics
NPI:1447775887
Name:PATTERSON, KELLY (PA-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 CYPRESS WAY
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6885
Mailing Address - Country:US
Mailing Address - Phone:435-512-9597
Mailing Address - Fax:
Practice Address - Street 1:77 W FOREST AVE STE 301
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1483
Practice Address - Country:US
Practice Address - Phone:928-773-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ14079288Medicaid