Provider Demographics
NPI:1376038695
Name:KELLY, RAYMOND JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOSEPH
Last Name:KELLY
Suffix:
Gender:M
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 1:401 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4614
Mailing Address - Country:US
Mailing Address - Phone:631-805-1462
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHERN BLVD STE 121
Practice Address - Street 2:
Practice Address - City:EAST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11548-1220
Practice Address - Country:US
Practice Address - Phone:516-705-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant