Provider Demographics
NPI:1104356377
Name:KELLY, ANDREW NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:NICHOLAS
Last Name:KELLY
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 1:129 W 29TH ST FL 10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5105
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:415-520-0904
Practice Address - Street 1:589 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2711
Practice Address - Country:US
Practice Address - Phone:212-658-6791
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024491363A00000X, 363AM0700X
PAMA059231363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant