Provider Demographics
NPI:1033348735
Name:BURGESS, KELLY A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:F
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 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:630-323-5309
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:630-323-5309
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant