Provider Demographics
NPI:1730135922
Name:LUEDERS, KELLY ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:LUEDERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3101 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4900
Mailing Address - Country:US
Mailing Address - Phone:479-250-1053
Mailing Address - Fax:479-250-0923
Practice Address - Street 1:3101 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4900
Practice Address - Country:US
Practice Address - Phone:479-250-1053
Practice Address - Fax:479-250-0923
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1191363A00000X
ARP-T1021363AM0700X
MO2009009834363AM0700X
ARPA-443363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5V349OtherAR BC/BS
OK100768880IMedicaid
OK100768880JMedicaid
OKP58368Medicare UPIN
AR56750P300Medicare PIN
AR5B836P300Medicare PIN
OK100768880JMedicaid
OK100768880IMedicaid
OK246727704Medicare PIN