Provider Demographics
NPI:1942924907
Name:CONDON, KACIE KLINE (PA-C)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:KLINE
Last Name:CONDON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:ALLISON
Other - Last Name:KLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1957 PORT CHELSEA PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5349
Mailing Address - Country:US
Mailing Address - Phone:949-922-1314
Mailing Address - Fax:
Practice Address - Street 1:420 E 3RD ST STE 805
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1646
Practice Address - Country:US
Practice Address - Phone:213-218-3915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant