Provider Demographics
NPI:1942441191
Name:BYRUM, KELLY V (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:V
Last Name:BYRUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:VAUGHAN
Other - Last Name:PADGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6350 CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4107
Mailing Address - Country:US
Mailing Address - Phone:757-905-5558
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:3000 COLISEUM DR
Practice Address - Street 2:SUITE 104
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-827-9400
Practice Address - Fax:757-827-9320
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00724783OtherRAILROAD MEDICARE
VA1942441191OtherOPTIMA
VA1942441191Medicaid
VA1942441191Medicaid