Provider Demographics
NPI:1619792934
Name:DUFFY, KERRY CAVAN (PA-S1)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:CAVAN
Last Name:DUFFY
Suffix:
Gender:M
Credentials:PA-S1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 IRIS WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2495
Mailing Address - Country:US
Mailing Address - Phone:509-945-7660
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-457-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program