Provider Demographics
NPI:1053777342
Name:ACOSTA, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:ACOSTA
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 1:275 N CHORRO ST
Mailing Address - Street 2:APT E
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-3320
Mailing Address - Country:US
Mailing Address - Phone:808-640-2660
Mailing Address - Fax:
Practice Address - Street 1:275 N CHORRO ST
Practice Address - Street 2:APT E
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3320
Practice Address - Country:US
Practice Address - Phone:808-640-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-03
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical