Provider Demographics
NPI:1710989439
Name:HALL, KELLY RUTHERFORD S (PA-C)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:RUTHERFORD S
Last Name:HALL
Suffix:
Gender:
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 1:227 W JANSS RD STE 340
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1879
Mailing Address - Country:US
Mailing Address - Phone:805-852-9100
Mailing Address - Fax:
Practice Address - Street 1:227 W JANSS RD STE 340
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1879
Practice Address - Country:US
Practice Address - Phone:805-852-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13266363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086630Medicaid
WPA13266FMedicare ID - Type UnspecifiedMEDICARE PPIN
CAR23506Medicare UPIN
W14069Medicare ID - Type Unspecified
CAZZZ07779ZOtherBLUE SHIELD
CAWPA13266GMedicare ID - Type UnspecifiedMEDICARE PPIN NUMBER
CAGR0087650Medicaid