Provider Demographics
NPI:1053303396
Name:KELLEY, CATHY (PA)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:ANNE
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:15650 N BLACK CANYON HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4064
Mailing Address - Country:US
Mailing Address - Phone:602-866-0550
Mailing Address - Fax:602-993-5788
Practice Address - Street 1:2030 W WHISPERING WIND DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2853
Practice Address - Country:US
Practice Address - Phone:602-866-0550
Practice Address - Fax:602-993-5788
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ387391Medicaid