Provider Demographics
NPI:1326192493
Name:JUAREZ, KELLY SHORES (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SHORES
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:SHORES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5569
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-4001
Practice Address - Fax:703-776-7113
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003194363AS0400X, 363A00000X
CA22892363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical