Provider Demographics
NPI:1063247153
Name:MCGUIRE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCGUIRE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 FIFTH AVE STE 340
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3138
Mailing Address - Country:US
Mailing Address - Phone:582-500-2868
Mailing Address - Fax:
Practice Address - Street 1:3900 FIFTH AVE STE 340
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3138
Practice Address - Country:US
Practice Address - Phone:582-500-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant