Provider Demographics
NPI:1205026861
Name:SALES, KELLY T (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:T
Last Name:SALES
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 1:477 N EL CAMINO REAL STE A306
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1350
Mailing Address - Country:US
Mailing Address - Phone:609-420-1187
Mailing Address - Fax:760-942-5319
Practice Address - Street 1:3230 WARING CT STE J
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4509
Practice Address - Country:US
Practice Address - Phone:760-941-4498
Practice Address - Fax:760-941-6938
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 19297OtherSTATE LICENSE NUMBER