1801556212 NPI number — KAYLEA A DERUELLE PA-C

Table of content: KAYLEA A DERUELLE PA-C (NPI 1801556212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801556212 NPI number — KAYLEA A DERUELLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERUELLE
Provider First Name:
KAYLEA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHRISMAN
Provider Other First Name:
KAYLEA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801556212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
810 CLAIRTON BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15236-4519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-466-5004
Provider Business Mailing Address Fax Number:
412-466-7137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 CLAIRTON BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15236-4519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-466-5004
Provider Business Practice Location Address Fax Number:
412-466-7137
Provider Enumeration Date:
12/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA063096 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA063096 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1037308370002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1037308370003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1037308370001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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