Basic Information
| Provider Information | |||||||||
| NPI: | 1225110224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEHL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 N MALACATE ST | ||||||||
| Address2: | |||||||||
| City: | AJO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853212254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
| FaxNumber: | 5203876036 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 N MALACATE ST | ||||||||
| Address2: | |||||||||
| City: | AJO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853212254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
| FaxNumber: | 5203876036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3035 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 890518 | 01 | AZ | AHCCCS | OTHER | 890518-02 | 05 | AZ | MEDICAID |