Provider Demographics
NPI:1942486212
Name:KREGER, KELLEN LANE (RPA-C)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:LANE
Last Name:KREGER
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2435
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-271-4508
Practice Address - Fax:607-735-5738
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012203-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY029169801Medicaid
NYJ400066836Medicare PIN