Provider Demographics
NPI:1306834783
Name:KELLY, CHRISTOPHER P (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6615
Mailing Address - Country:US
Mailing Address - Phone:727-734-4000
Mailing Address - Fax:727-738-5037
Practice Address - Street 1:703 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698
Practice Address - Country:US
Practice Address - Phone:727-734-4000
Practice Address - Fax:727-738-5037
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291709200Medicaid
FLE3140XMedicare PIN
FLS90139Medicare UPIN
FL970027335Medicare PIN