Provider Demographics
NPI:1871958942
Name:KOLODGE, KAITLEN ELIZABETH (MS, PA-C)
Entity type:Individual
Prefix:MS
First Name:KAITLEN
Middle Name:ELIZABETH
Last Name:KOLODGE
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:KAITLEN
Other - Middle Name:
Other - Last Name:LAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4445 EASTGATE MALL
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1979
Mailing Address - Country:US
Mailing Address - Phone:858-357-9450
Mailing Address - Fax:858-412-6376
Practice Address - Street 1:955 LANE AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4525
Practice Address - Country:US
Practice Address - Phone:619-421-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53094363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1871958942Medicaid