Provider Demographics
NPI:1073664793
Name:KELLEY, GEORGIE (PA)
Entity Type:Individual
Prefix:
First Name:GEORGIE
Middle Name:
Last Name:KELLEY
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 1:1400 POTTERY AVE
Mailing Address - Street 2:PORT ORCHARD MEDICAL CENTER
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3768
Mailing Address - Country:US
Mailing Address - Phone:360-895-5000
Mailing Address - Fax:360-895-5034
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-383-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003604363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8399370Medicaid
WAG8858780Medicare PIN
WAG8858784Medicare PIN
WAS46351Medicare UPIN
WAG8872401Medicare PIN
WAG8858781Medicare PIN
WAG8858782Medicare PIN
WA8399370Medicaid