Basic Information
| Provider Information | |||||||||
| NPI: | 1053575746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDLY | ||||||||
| FirstName: | KIRT | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | D.C., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1730 | ||||||||
| Address2: | |||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922701058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605682684 | ||||||||
| FaxNumber: | 7603415832 | ||||||||
| Practice Location | |||||||||
| Address1: | 39000 BOB HOPE DR | ||||||||
| Address2: | HARRY & DIANE RINKER BUILDING | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922703221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605682684 | ||||||||
| FaxNumber: | 7603415832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA21381 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA21381 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA21381 | 01 | CA | CALIFORNIA LICENSE | OTHER |