Provider Demographics
NPI:1194343731
Name:KALBAUGH, KELLAN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLAN
Middle Name:
Last Name:KALBAUGH
Suffix:
Gender:M
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 1:1941 JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4154
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-782-8859
Practice Address - Street 1:1941 JOHNSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4154
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:805-782-8859
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60114363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty