Provider Demographics
NPI:1790745347
Name:FAMA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 9TH AVE
Mailing Address - Street 2:STATION MEDICAL CENTER
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 N JUNIATA ST
Practice Address - Street 2:FIRST FLOOR SUITE
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-1455
Practice Address - Country:US
Practice Address - Phone:814-695-5591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002053L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1883336OtherHIGHMARK
PA1883336OtherHIGHMARK
PA007771Medicare UPIN