MEDICARE: KELLI ELAINE FATHEREE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA200105RX	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01226202	OTHER	TX	RAILROAD PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225061435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI ELAINE FATHEREE PA-C

Provider Business Mailing Address
First Line	:	7460 WARREN PKWY
Second Line	:	SUITE 160
City	:	FRISCO
State	:	TX
Zip	:	75034
Country	:	US
Telephone Number	:	972-668-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	7460 WARREN PKWY
Second Line	:	SUITE 160
City	:	FRISCO
State	:	TX
Zip	:	75034-4169
Country	:	US
Telephone Number	:	972-668-5400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	11/22/2013

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