Healthcare Provider Details

I. General information

NPI: 1508041583
Provider Name (Legal Business Name): KELLY MACKENZIE ARDITI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY M ARDITI PA

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 VAN NESS AVENUE SUITE 302
SAN FRANCISCO CA
94102
US

IV. Provider business mailing address

77 VAN NESS AVENUE SUITE 302
SAN FRANCISCO CA
94102
US

V. Phone/Fax

Practice location:
  • Phone: 415-379-9015
  • Fax: 415-379-9045
Mailing address:
  • Phone: 415-379-9015
  • Fax: 415-379-9045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: