Provider Demographics
NPI:1164852216
Name:POWERS, KELLEY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ELIZABETH
Last Name:POWERS
Suffix:
Gender:F
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 1:1547 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9543
Mailing Address - Country:US
Mailing Address - Phone:518-479-4156
Mailing Address - Fax:518-479-3794
Practice Address - Street 1:1547 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9543
Practice Address - Country:US
Practice Address - Phone:518-479-4156
Practice Address - Fax:518-479-3794
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017206363A00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW34181OtherMEDICARE PTAN
NYAA0422OtherMEDICARE PTAN
NYBA0876OtherMEDICARE PTAN
NYW34181OtherMEDICARE PTAN
NYJ400112581Medicare PIN
NYJ400112580Medicare PIN