Provider Demographics
NPI:1164838900
Name:KELLY, CHRISTOPHER TRAVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:TRAVIS
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:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:2155 CITY GATE LN
Practice Address - Street 2:SUITE 225
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-7733
Practice Address - Country:US
Practice Address - Phone:630-547-5040
Practice Address - Fax:630-305-0094
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.005054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant