Provider Demographics
NPI:1124450143
Name:MORIN, KELLY A (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MORIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12812 LA MAIDA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3315
Mailing Address - Country:US
Mailing Address - Phone:313-204-0946
Mailing Address - Fax:
Practice Address - Street 1:7300 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1902
Practice Address - Country:US
Practice Address - Phone:818-676-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant