Provider Demographics
NPI:1992789739
Name:RIDGE, KELLY R (PAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:RIDGE
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:3 WASHINGTON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1010
Mailing Address - Country:US
Mailing Address - Phone:508-205-9630
Mailing Address - Fax:508-796-2610
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2025-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA1104363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1274Medicare UPIN