Provider Demographics
NPI:1669796926
Name:KEHOE, KRISTY A (PA)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:A
Last Name:KEHOE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:M
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5400 E. TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-675-1313
Mailing Address - Fax:888-965-0619
Practice Address - Street 1:5400 E. TEXAS ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-675-1313
Practice Address - Fax:888-965-0619
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823007Medicaid