Provider Demographics
NPI:1942235247
Name:KRUSE, KELLY BAILEY (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BAILEY
Last Name:KRUSE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2093 HENRY TECKLENBURG DR STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5742
Practice Address - Country:US
Practice Address - Phone:843-958-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC496363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00727284OtherRAILROAD MEDICARE ID-RSFPP
SCP00615390OtherRAILROAD MEDICARE ID
SC0655PAMedicaid
SCP00727284OtherRAILROAD MEDICARE ID-RSFPP
SCQ316259223Medicare PIN