Healthcare Provider Details

I. General information

NPI: 1104655257
Provider Name (Legal Business Name): KELLY L SALAZAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 BROCKTON AVE
RIVERSIDE CA
92506-0102
US

IV. Provider business mailing address

4646 BROCKTON AVE
RIVERSIDE CA
92506-0102
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-6900
  • Fax:
Mailing address:
  • Phone: 951-682-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: