Provider Demographics
NPI:1710989439
Name:HALL, KELLY RUTHERFORD S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:RUTHERFORD S
Last Name:HALL
Suffix:
Gender:M
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5849
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 4300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13266363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086630Medicaid
WPA13266FMedicare ID - Type UnspecifiedMEDICARE PPIN
CAR23506Medicare UPIN
W14069Medicare ID - Type Unspecified
CAZZZ07779ZOtherBLUE SHIELD
CAWPA13266GMedicare ID - Type UnspecifiedMEDICARE PPIN NUMBER
CAGR0087650Medicaid