Provider Demographics
NPI:1407137110
Name:KELLY, CHRISTOPHER PATRICK (PAC)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5885
Practice Address - Street 1:202 LARRY JOE HARLESS DR.
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621-1842
Practice Address - Country:US
Practice Address - Phone:304-664-6270
Practice Address - Fax:304-664-6272
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2800363A00000X
WV01578363A00000X
WV601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810025900Medicaid
WVWV0394IMedicare Oscar/Certification
WVWV0394JMedicare Oscar/Certification
WVWV0394FMedicare Oscar/Certification
WVWV0394GMedicare Oscar/Certification
WVWV0394B663Medicare Oscar/Certification
WVWV0394HMedicare Oscar/Certification
WV3810025900Medicaid
WVWV0394LMedicare Oscar/Certification
WVWV0394KMedicare Oscar/Certification
WVWV0394B662Medicare Oscar/Certification