Provider Demographics
NPI:1558797563
Name:THOMAS, KELLEY BRIDGET (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:BRIDGET
Last Name:THOMAS
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 1:38731 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3210
Mailing Address - Country:US
Mailing Address - Phone:586-939-8480
Mailing Address - Fax:
Practice Address - Street 1:38731 MOUND RD
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3210
Practice Address - Country:US
Practice Address - Phone:586-939-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant