Provider Demographics
NPI:1013681451
Name:MATSON, KELLIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:MATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3211
Mailing Address - Country:US
Mailing Address - Phone:610-506-7336
Mailing Address - Fax:
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:484-337-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine