Provider Demographics
NPI:1730135922
Name:LUEDERS, KELLY ANN (DMS, PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:LUEDERS
Suffix:
Gender:F
Credentials:DMS, PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2110 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3246
Mailing Address - Country:US
Mailing Address - Phone:479-202-7035
Mailing Address - Fax:
Practice Address - Street 1:2110 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3246
Practice Address - Country:US
Practice Address - Phone:479-202-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1191363A00000X
ARPA-443363AM0700X, 363A00000X, 363A00000X
MO2009009834363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768880IMedicaid
OK100768880JMedicaid
AR5V349OtherAR BC/BS
OKP58368Medicare UPIN
AR56750P300Medicare PIN
AR5B836P300Medicare PIN
OK100768880JMedicaid
OK100768880IMedicaid
OK246727704Medicare PIN