Provider Demographics
NPI:1275798332
Name:MCRAE, KELLY SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SHANNON
Last Name:MCRAE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SHANNON
Other - Last Name:HEDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18051 RIVER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7091
Mailing Address - Country:US
Mailing Address - Phone:317-773-0002
Mailing Address - Fax:
Practice Address - Street 1:18051 RIVER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7091
Practice Address - Country:US
Practice Address - Phone:317-773-0002
Practice Address - Fax:317-776-6095
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000446A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151560TTMedicare PIN