Provider Demographics
NPI:1306865423
Name:KELLY, ELAINE D (PA-C)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:D
Last Name:KELLY
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 1:1ST AVE W & MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630
Mailing Address - Country:US
Mailing Address - Phone:218-835-5837
Mailing Address - Fax:218-835-4222
Practice Address - Street 1:1ST AVE W & MARGARET ST
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630
Practice Address - Country:US
Practice Address - Phone:218-835-5837
Practice Address - Fax:218-835-4222
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9428363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN180115500Medicaid
MN180115500Medicaid
MN970000449Medicare PIN