Provider Demographics
NPI:1043316532
Name:KELLY, RUSSELL AARON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:AARON
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21 MAPLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1942
Mailing Address - Country:US
Mailing Address - Phone:617-947-3258
Mailing Address - Fax:
Practice Address - Street 1:103 MYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1598
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0009706OtherMEDICARE PTAN