Provider Demographics
NPI:1790838621
Name:SVEDBERG, KELLY G (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:SVEDBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7819 JAARS RD
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7677
Mailing Address - Country:US
Mailing Address - Phone:704-350-5885
Mailing Address - Fax:936-244-4599
Practice Address - Street 1:331 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5384
Practice Address - Country:US
Practice Address - Phone:704-350-5885
Practice Address - Fax:936-244-4599
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10819363A00000X
SCPA1575363A00000X, 363A00000X
NC0010-00631363A00000X
TX10819363AM0700X
NC001000631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical