Provider Demographics
NPI:1073571816
Name:KELLEY, MICHAEL TIMOTHY (MS PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 E MERCER LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-2530
Mailing Address - Country:US
Mailing Address - Phone:602-799-3181
Mailing Address - Fax:
Practice Address - Street 1:6625 S RURAL RD STE 104
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3717
Practice Address - Country:US
Practice Address - Phone:480-833-4515
Practice Address - Fax:480-833-5078
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
AZAZ3829363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ3829OtherARIZONA STATE LICENSE NUMBER
AZ585950Medicaid
AZ585950Medicaid