Provider Demographics
NPI:1053575746
Name:EDLY, KIRT LEE (PA)
Entity type:Individual
Prefix:
First Name:KIRT
Middle Name:LEE
Last Name:EDLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1058
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:760-341-5832
Practice Address - Street 1:39000 BOB HOPE DR, HARRY & DIANE RINKER BUILDING
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-341-5832
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21381363AS0400X, 363AM0700X
IL085003072363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21381OtherCALIFORNIA LICENSE