Provider Demographics
NPI:1306988191
Name:CAMERON, KELLY PRIMROSE (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:PRIMROSE
Last Name:CAMERON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:PRIMROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 OHIO RIVER BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-1300
Mailing Address - Country:US
Mailing Address - Phone:412-741-6530
Mailing Address - Fax:412-741-9274
Practice Address - Street 1:301 OHIO RIVER BLVD STE 301
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-1300
Practice Address - Country:US
Practice Address - Phone:412-741-6530
Practice Address - Fax:412-741-9274
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103201435Medicaid