MEDICARE: MISS KELLY JEAN KALDENBACH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679687206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KELLY JEAN KALDENBACH PA-C

Provider Business Mailing Address
First Line	:	891 EUREKA ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5807
Country	:	US
Telephone Number	:	817-341-7600
Fax Number	:	817-341-7351

Provider Business Practice Location Address
First Line	:	891 EUREKA ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5807
Country	:	US
Telephone Number	:	817-341-7600
Fax Number	:	817-341-7351

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	01/14/2015

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