Healthcare Provider Details

I. General information

NPI: 1487601886
Provider Name (Legal Business Name): KELLY CHRISTINE MUTSAVAGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 ALDEN ST
MEADVILLE PA
16335-2348
US

IV. Provider business mailing address

640 ALDEN ST
MEADVILLE PA
16335-2348
US

V. Phone/Fax

Practice location:
  • Phone: 814-724-1252
  • Fax: 814-333-8871
Mailing address:
  • Phone: 814-724-1252
  • Fax: 814-333-8871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052475
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002277
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMA052475
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMA052475
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: