Provider Demographics
NPI:1568454098
Name:KELLEY, JOHN S (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3400 E FRANK PHILLIPS BLVD
Mailing Address - Street 2:SUITE 602
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2495
Mailing Address - Country:US
Mailing Address - Phone:918-331-2440
Mailing Address - Fax:918-331-2433
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2495
Practice Address - Country:US
Practice Address - Phone:918-331-2440
Practice Address - Fax:918-331-2433
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant