Provider Demographics
NPI:1154609790
Name:MERCER, KELLY CHRISTINE (PA-C, MPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:MERCER
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-584-1612
Mailing Address - Fax:619-578-2588
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-584-1612
Practice Address - Fax:619-578-2588
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21625OtherPHYSICIAN ASSISTANT LICENSE