Provider Demographics
NPI:1275762775
Name:KELLY, JOSEPH MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:MICHAEL
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 1:19070 E SUNLIGHT WAY
Mailing Address - Street 2:MS 7
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-9574
Mailing Address - Country:US
Mailing Address - Phone:720-847-8652
Mailing Address - Fax:720-847-8645
Practice Address - Street 1:19070 E SUNLIGHT WAY
Practice Address - Street 2:BLDG 1000
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-9574
Practice Address - Country:US
Practice Address - Phone:720-847-8652
Practice Address - Fax:720-847-8645
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00699363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical