Provider Demographics
NPI:1194099499
Name:GAST, KELLY A (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GAST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 N DUKE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2374
Mailing Address - Country:US
Mailing Address - Phone:717-544-4995
Mailing Address - Fax:717-544-4944
Practice Address - Street 1:540 N DUKE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2374
Practice Address - Country:US
Practice Address - Phone:717-544-4995
Practice Address - Fax:717-544-4944
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055380363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA238281Medicare PIN