Provider Demographics
NPI:1841881778
Name:PERHAM, KELLYN ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLYN
Middle Name:ROSE
Last Name:PERHAM
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 1:520 SUPERIOR AVE STE 370
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3623
Mailing Address - Country:US
Mailing Address - Phone:949-574-7176
Mailing Address - Fax:949-574-7180
Practice Address - Street 1:520 SUPERIOR AVE STE 370
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3623
Practice Address - Country:US
Practice Address - Phone:949-574-7176
Practice Address - Fax:949-574-7180
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant