Provider Demographics
NPI:1497109300
Name:KRUPA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRUPA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4756
Mailing Address - Country:US
Mailing Address - Phone:412-359-6907
Mailing Address - Fax:
Practice Address - Street 1:1415 PORTLAND AVE STE 245
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3022
Practice Address - Country:US
Practice Address - Phone:585-922-4518
Practice Address - Fax:585-922-3950
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315584208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery