Provider Demographics
NPI:1902131592
Name:RUEDA, KELLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:RUEDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79105-0201
Mailing Address - Country:US
Mailing Address - Phone:806-358-9400
Mailing Address - Fax:
Practice Address - Street 1:1000 CRAIG DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4015
Practice Address - Country:US
Practice Address - Phone:806-331-7905
Practice Address - Fax:806-731-1516
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8374NJOtherBCBS
TXP00794740OtherMEDICARE RR
TX8L20653Medicare PIN
TX363239ZHVZMedicare PIN