Provider Demographics
NPI:1255426870
Name:MERCADO, KELLI ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLI ANN
Middle Name:
Last Name:MERCADO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KELLI ANN
Other - Middle Name:
Other - Last Name:DIPATRIZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2700 N 140TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2439
Mailing Address - Country:US
Mailing Address - Phone:623-535-8770
Mailing Address - Fax:623-535-8771
Practice Address - Street 1:2700 N 140TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2439
Practice Address - Country:US
Practice Address - Phone:623-535-8770
Practice Address - Fax:623-535-8771
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3060363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ28794Medicare UPIN