Provider Demographics
NPI:1801951702
Name:PHANH, KELLY C (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:PHANH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3144 G ST STE 125 PMB 293
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-1385
Mailing Address - Country:US
Mailing Address - Phone:209-383-3990
Mailing Address - Fax:209-383-2082
Practice Address - Street 1:394 E YOSEMITE AVE STE 200
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8218
Practice Address - Country:US
Practice Address - Phone:209-383-3990
Practice Address - Fax:209-383-2082
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP34728Medicare UPIN
CA0PA152890Medicare ID - Type Unspecified