Provider Demographics
NPI:1740524180
Name:FOSTER, KELLEY FOSTER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:FOSTER
Last Name:FOSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KELLEY
Other - Middle Name:SHEA
Other - Last Name:HITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:350 STEELES RD
Mailing Address - Street 2:STE 1
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-844-6600
Mailing Address - Fax:423-968-1255
Practice Address - Street 1:350 STEELES RD
Practice Address - Street 2:STE 1
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-844-6600
Practice Address - Fax:423-968-1255
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100251670Medicaid
TNQ000294Medicaid
VA1740524180Medicaid
VA1740524180Medicaid