Provider Demographics
NPI:1194255646
Name:MEREDITH, KELLEY EVANS (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:EVANS
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 SABOT HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-3006
Mailing Address - Country:US
Mailing Address - Phone:804-357-2964
Mailing Address - Fax:
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-388-4333
Practice Address - Fax:541-388-3446
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant