Provider Demographics
NPI:1508041583
Name:ARDITI, KELLY MACKENZIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MACKENZIE
Last Name:ARDITI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:ARDITI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:77 VAN NESS AVENUE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102
Mailing Address - Country:US
Mailing Address - Phone:415-379-9015
Mailing Address - Fax:415-379-9045
Practice Address - Street 1:77 VAN NESS AVENUE
Practice Address - Street 2:SUITE 302
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102
Practice Address - Country:US
Practice Address - Phone:415-379-9015
Practice Address - Fax:415-379-9045
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant