Provider Demographics
NPI:1689956641
Name:KELLY, ANDREA MALUTA (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MALUTA
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:MALUTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:13808 PROFESSIONAL CENTER DR STE 302
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:704-602-4381
Practice Address - Street 1:2015 RANDOLPH RD STE 208
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1241
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001004126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2531PAMedicaid
NC1689956641Medicaid
NCNCK174CMedicare UPIN
SC2531PAMedicaid
NCNCK174DMedicare UPIN
NCNCK174BMedicare UPIN
NCNCK174EMedicare UPIN