Provider Demographics
NPI:1487601886
Name:MUTSAVAGE, KELLY CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:MUTSAVAGE
Suffix:
Gender:F
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 1:640 ALDEN ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2348
Mailing Address - Country:US
Mailing Address - Phone:814-724-1252
Mailing Address - Fax:814-333-8871
Practice Address - Street 1:640 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2348
Practice Address - Country:US
Practice Address - Phone:814-724-1252
Practice Address - Fax:814-333-8871
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052475207N00000X, 363A00000X, 208M00000X
PAOA002277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ69615Medicare UPIN
PA109605EMHMedicare PIN
PA157806ZC4DMedicare PIN
PA192105ZC4DMedicare PIN