Provider Demographics
NPI:1740791623
Name:GAYDOSH, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GAYDOSH
Suffix:
Gender:F
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 1:12692 PIONEER TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-3756
Mailing Address - Country:US
Mailing Address - Phone:440-821-4241
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005295RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant