Provider Demographics
NPI:1851676118
Name:NOLD, KELLEN AARON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KELLEN
Middle Name:AARON
Last Name:NOLD
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 1:1100 9TH AVE
Mailing Address - Street 2:MS:M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:MS:X7-NS
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-341-0182
Practice Address - Fax:206-341-0091
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00270600363A00000X
WAPA60373777363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01229427OtherRAILROAD
WA1851676118Medicaid
WA1851676118Medicaid