Provider Demographics
NPI:1407942097
Name:KELLEY, ROSEMARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:KELLEY
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 1:1441 FLORIDA AVE
Mailing Address - Street 2:GREATER MODESTO MEDICAL SURGICAL ASSOCIATES
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4404
Mailing Address - Country:US
Mailing Address - Phone:209-576-3601
Mailing Address - Fax:209-576-3680
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:DOCTOR'S MEDICAL CENTER - NEURO ICU
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-576-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13565363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherGROUP PTAN
CAP86258Medicare UPIN