1730135922 NPI number — MS. KELLY ANN LUEDERS DMS, PA-C

Table of content: MS. KELLY ANN LUEDERS DMS, PA-C (NPI 1730135922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730135922 NPI number — MS. KELLY ANN LUEDERS DMS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUEDERS
Provider First Name:
KELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DMS, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIOTT
Provider Other First Name:
KELLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730135922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 W WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72756-3246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-202-7035
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 W WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72756-3246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-202-7035
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1191 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA-443 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA-443 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 2009009834 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100768880I , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100768880J , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5V349 . This is a "AR BC/BS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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