Provider Demographics
NPI:1477059228
Name:TWEDELL, KELLI (PA-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:TWEDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:KAUFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3409
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78691-3409
Mailing Address - Country:US
Mailing Address - Phone:513-252-7792
Mailing Address - Fax:513-904-5908
Practice Address - Street 1:5744 LBJ FWY STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6322
Practice Address - Country:US
Practice Address - Phone:214-466-2828
Practice Address - Fax:214-382-9798
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11922363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX382709902Medicaid
TXPA11922OtherTEXAS MEDICAL BOARD