Provider Demographics
NPI:1033367180
Name:SKELLY, EDITH LUZ (PA)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:LUZ
Last Name:SKELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EDITH
Other - Middle Name:LUZ
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:90 VANDENBERG DR
Mailing Address - Street 2:
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA2532363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical