Provider Demographics
NPI:1679687206
Name:KALDENBACH, KELLY JEAN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:JEAN
Last Name:KALDENBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5807
Mailing Address - Country:US
Mailing Address - Phone:817-341-7600
Mailing Address - Fax:817-341-7351
Practice Address - Street 1:891 EUREKA ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5807
Practice Address - Country:US
Practice Address - Phone:817-341-7600
Practice Address - Fax:817-341-7351
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200945803Medicaid
TX366070YKR0Medicare PIN
TXTXB138233Medicare PIN
TX200945803Medicaid