Provider Demographics
NPI:1730701285
Name:FRUTH, KELLY
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:FRUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:MSS
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4207
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:520 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5535
Practice Address - Country:US
Practice Address - Phone:541-472-7810
Practice Address - Fax:541-472-7811
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57800363A00000X
ORPA214041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant