Provider Demographics
NPI:1427376342
Name:SUAREZ, KELLY JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JENNIFER
Last Name:SUAREZ
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 1:231 GODWIN AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3709
Mailing Address - Country:US
Mailing Address - Phone:786-296-2309
Mailing Address - Fax:
Practice Address - Street 1:480 RED HILL RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748
Practice Address - Country:US
Practice Address - Phone:848-225-6331
Practice Address - Fax:212-717-3169
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105022363A00000X
NJ25MP00465900363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant