Provider Demographics
NPI:1407129414
Name:MCGRATH, KELLY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MCGRATH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2605 E CREEKS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8368
Mailing Address - Country:US
Mailing Address - Phone:812-333-2663
Mailing Address - Fax:812-349-9206
Practice Address - Street 1:2605 E CREEKS EDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8368
Practice Address - Country:US
Practice Address - Phone:812-333-2663
Practice Address - Fax:812-349-9206
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-04175363A00000X
AL789363A00000X
IN10002267A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCC955AMedicare Oscar/Certification