Provider Demographics
NPI:1518116359
Name:MCNULTY, KELLY P (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SAINT CHARLES WAY
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-4643
Mailing Address - Country:US
Mailing Address - Phone:717-741-4666
Mailing Address - Fax:717-741-0538
Practice Address - Street 1:205 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4643
Practice Address - Country:US
Practice Address - Phone:717-741-4666
Practice Address - Fax:717-741-0538
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2696616OtherHIGHMARK BLUE SHIELD - FREEDOM BLUE
PA239152FLTMedicare PIN
PA138100Medicare PIN
PA138100Medicare PIN