Provider Demographics
NPI:1013955798
Name:PRIDGEN, KELLY DEAN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DEAN
Last Name:PRIDGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1601 SE COURT AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3217
Practice Address - Country:US
Practice Address - Phone:541-276-5121
Practice Address - Fax:541-278-3661
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD24109207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0224305OtherLIWA
OR181590Medicaid
ORG20977Medicare UPIN
WAG8327017Medicare PIN
OR181590Medicaid
ORR131329Medicare PIN
ORP00366332Medicare PIN