Provider Demographics
NPI:1891995296
Name:EARLE P.A., KELLIE M (PA)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:M
Last Name:EARLE P.A.
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 SO FERN CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296
Mailing Address - Country:US
Mailing Address - Phone:480-751-3091
Mailing Address - Fax:480-751-3095
Practice Address - Street 1:4135 SO. POWER RD
Practice Address - Street 2:SUITE 129
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212
Practice Address - Country:US
Practice Address - Phone:480-751-3091
Practice Address - Fax:480-751-3095
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3636363AM0700X
NY010832363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ60219Medicare UPIN