Provider Demographics
NPI:1598885170
Name:KELLY, CORIE S (PA)
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:525 S WATSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3451
Mailing Address - Country:US
Mailing Address - Phone:602-726-8750
Mailing Address - Fax:236-474-5811
Practice Address - Street 1:525 S WATSON RD STE 200
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3451
Practice Address - Country:US
Practice Address - Phone:602-726-8750
Practice Address - Fax:236-474-5811
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121015Medicare PIN