Provider Demographics
NPI:1366905705
Name:TATRO, KELLIE DEANNE (PA-C, RRA, RT(R))
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:DEANNE
Last Name:TATRO
Suffix:
Gender:F
Credentials:PA-C, RRA, RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 W ARLINGTON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5758
Mailing Address - Country:US
Mailing Address - Phone:252-752-5000
Mailing Address - Fax:
Practice Address - Street 1:2101 W ARLINGTON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5758
Practice Address - Country:US
Practice Address - Phone:252-752-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
349813243U00000X
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant