Provider Demographics
NPI:1104441021
Name:TELLACHE, KIRA ANN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:ANN
Last Name:TELLACHE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8860 CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7001
Mailing Address - Country:US
Mailing Address - Phone:619-462-1670
Mailing Address - Fax:619-462-3209
Practice Address - Street 1:8860 CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7001
Practice Address - Country:US
Practice Address - Phone:619-462-1670
Practice Address - Fax:619-462-3209
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty