Healthcare Provider Details

I. General information

NPI: 1730701285
Provider Name (Legal Business Name): MS. KELLY FRUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SW RAMSEY AVE
GRANTS PASS OR
97527-5535
US

IV. Provider business mailing address

2825 E BARNETT RD MSS
MEDFORD OR
97504-8332
US

V. Phone/Fax

Practice location:
  • Phone: 541-472-7810
  • Fax: 541-472-7811
Mailing address:
  • Phone: 541-789-4207
  • Fax: 541-789-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57800
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA214041
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: