Provider Demographics
NPI:1700817483
Name:HUESMAN, KELLI KRISTINA (PA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KRISTINA
Last Name:HUESMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WYOMING ST
Mailing Address - Street 2:SUITE 3272
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2722
Mailing Address - Country:US
Mailing Address - Phone:937-208-6790
Mailing Address - Fax:937-208-6797
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:SUITE 3272
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-6790
Practice Address - Fax:937-208-6797
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067486Medicaid
OH0067486Medicaid
OHPA19584Medicare PIN