Provider Demographics
NPI:1538677489
Name:ALFARO, KELLIE G (PA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:G
Last Name:ALFARO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:G
Other - Last Name:ALFARO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:801 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-587-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant