Healthcare Provider Details

I. General information

NPI: 1982960340
Provider Name (Legal Business Name): KELLY LEE SANTORO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12414 EXPOSITION BLVD
LOS ANGELES CA
90064-1016
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 310-272-7640
  • Fax: 310-272-7656
Mailing address:
  • Phone: 310-272-7648
  • Fax: 310-272-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055445
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51687
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number51687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: