Provider Demographics
NPI:1326260472
Name:TOLAR, KELLY B (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:TOLAR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:T
Other - Last Name:MCCARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 BOURLAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3594
Mailing Address - Country:US
Mailing Address - Phone:817-379-5100
Mailing Address - Fax:817-379-0479
Practice Address - Street 1:100 BOURLAND RD STE 100
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3594
Practice Address - Country:US
Practice Address - Phone:817-379-5100
Practice Address - Fax:817-379-0479
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04333OtherSTATE LICENSE
TXPA04333OtherSTATE LICENSE
TX8L19586Medicare PIN