Provider Demographics
NPI:1508973694
Name:KELLEY, HARLAN HUNT (MD)
Entity Type:Individual
Prefix:
First Name:HARLAN
Middle Name:HUNT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HIGHWAY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6401
Practice Address - Fax:505-368-6401
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37343207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47528257Medicaid
CO08234817Medicaid
AZ282639Medicaid
320059Medicare Oscar/Certification
8HH121Medicare PIN
NM47528257Medicaid