Provider Demographics
NPI:1073595104
Name:WARD, KELLY P (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:WARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 OGLETHORPE AVE STE 500B
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2184
Mailing Address - Country:US
Mailing Address - Phone:706-369-5440
Mailing Address - Fax:
Practice Address - Street 1:1500 OGLETHORPE AVE STE 500B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2184
Practice Address - Country:US
Practice Address - Phone:706-369-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA139754792AMedicaid
GA97BBCVQMedicare PIN
GA139754792AMedicaid