Provider Demographics
NPI:1083608244
Name:TOLER, KELLY W (PA C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:TOLER
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:2400 BELLEVUE RD
Practice Address - Street 2:16 ERIN OFC PARK
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2885
Practice Address - Country:US
Practice Address - Phone:478-275-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003418363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA479070329BMedicaid
GADC4061OtherRAILROAD MEDICARE
GA97WCFZHMedicare PIN
GADC4061OtherRAILROAD MEDICARE
GAGRP6800Medicare PIN