Provider Demographics
NPI:1710959317
Name:WRIGHT, KELLY L (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:LUKOVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2209 FIRESTONE TRCE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1188
Mailing Address - Country:US
Mailing Address - Phone:330-283-6218
Mailing Address - Fax:
Practice Address - Street 1:95 ARCH ST STE 201
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1437
Practice Address - Country:US
Practice Address - Phone:330-434-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002191363A00000X
363AM0700X, 2255A2300X, 363AS0400X
OH363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1710959317Medicaid
OH000000360053OtherANTHEM
OHPA78261Medicare ID - Type Unspecified