Healthcare Provider Details

I. General information

NPI: 1952221392
Provider Name (Legal Business Name): KEELY SHAY PERRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377A WALKER LN
SAN CLEMENTE CA
92672-2574
US

IV. Provider business mailing address

377A WALKER LN
SAN CLEMENTE CA
92672-2574
US

V. Phone/Fax

Practice location:
  • Phone: 504-275-0705
  • Fax:
Mailing address:
  • Phone: 504-275-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number68760
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: