Provider Demographics
NPI:1326093956
Name:DURHAM, KELLY RAE (PA C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RAE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:PA C
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Mailing Address - Street 1:PO BOX 986513
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6513
Mailing Address - Country:US
Mailing Address - Phone:910-219-8326
Mailing Address - Fax:910-939-4269
Practice Address - Street 1:1106 MAIN STREET EXT
Practice Address - Street 2:
Practice Address - City:SWANSBORO
Practice Address - State:NC
Practice Address - Zip Code:28584-9114
Practice Address - Country:US
Practice Address - Phone:910-325-0581
Practice Address - Fax:910-325-0582
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC101510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101003Medicaid