Provider Demographics
NPI:1407272578
Name:SWANSON, KELLY ANNE DOOLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY ANNE
Middle Name:DOOLEY
Last Name:SWANSON
Suffix:
Gender:F
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 1:5701 BOW POINTE DR STE 215
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5400
Mailing Address - Country:US
Mailing Address - Phone:248-620-3376
Mailing Address - Fax:
Practice Address - Street 1:5701 BOW POINTE DR STE 215
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5400
Practice Address - Country:US
Practice Address - Phone:248-620-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006918363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14750005Medicare PIN