Provider Demographics
NPI:1245857721
Name:KASPER, KELLIE ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:ANN
Last Name:KASPER
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 1:403 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2108
Mailing Address - Country:US
Mailing Address - Phone:609-927-8746
Mailing Address - Fax:609-601-1406
Practice Address - Street 1:403 BETHEL RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2108
Practice Address - Country:US
Practice Address - Phone:609-927-8746
Practice Address - Fax:609-653-8807
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00566600OtherNJ MEDICAL LICENSE