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General NPI Number Information
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NPI Number | 1730135922
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Entity Type | Individual
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Provider Name | KELLY ANN LUEDERS DMS, PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 06/26/2024
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Provider Practice Location Address
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Address Line | 2110 W WALNUT ST
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City | ROGERS
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State | AR
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Zip | 72756-3246
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Country | US
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Telephone | 479-202-7035
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Fax |
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Provider Business Mailing Address
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Address Line | 2110 W WALNUT ST
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City | ROGERS
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State | AR
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Zip | 72756-3246
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Country | US
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Telephone | 479-202-7035
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1191
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-443
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA-443
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License Number State | AR
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Taxonomy #4
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 2009009834
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License Number State | MO
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