Provider Demographics
NPI:1558704775
Name:KELLY, JOHN P (RPA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
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Mailing Address - Street 1:515 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5005
Mailing Address - Country:US
Mailing Address - Phone:516-799-2700
Mailing Address - Fax:516-799-8023
Practice Address - Street 1:515 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5005
Practice Address - Country:US
Practice Address - Phone:516-799-2700
Practice Address - Fax:516-799-8023
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY007491363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical