Provider Demographics
NPI:1891864849
Name:BELTRAN, KELLY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:BELTRAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1001 N BROADWAY
Mailing Address - Street 2:#A11
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1586
Mailing Address - Country:US
Mailing Address - Phone:425-259-0212
Mailing Address - Fax:425-259-0209
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18715363A00000X
WA60017286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18715Medicaid
CAPA18715Medicaid
CAWPA18715CMedicare PIN