Provider Demographics
NPI:1174718738
Name:CANTU, KELLY BLAKE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BLAKE
Last Name:CANTU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BLAKE
Other - Last Name:RYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2000 CENTER POINT RD STE 2360
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5826
Mailing Address - Country:US
Mailing Address - Phone:803-233-5500
Mailing Address - Fax:803-258-6395
Practice Address - Street 1:2000 CENTER POINT RD STE 2360
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5826
Practice Address - Country:US
Practice Address - Phone:803-233-5500
Practice Address - Fax:803-258-6395
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17702520172081P2900X
CT002185363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174718738OtherNPI