Provider Demographics
NPI:1093385213
Name:MORALES, KELLIE (MSPAS, PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 E BEACH ST
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4809
Mailing Address - Country:US
Mailing Address - Phone:831-728-0222
Mailing Address - Fax:
Practice Address - Street 1:204 E BEACH ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4809
Practice Address - Country:US
Practice Address - Phone:831-728-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA61013OtherPHYSICIAN ASSISTANT BOARD
CAPA61013OtherPHYSICIAN ASSISTANT BOARD