Provider Demographics
NPI:1609849371
Name:KELLEY, JAMES L (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1322
Mailing Address - Country:US
Mailing Address - Phone:253-272-8148
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:2202 S CEDAR ST
Practice Address - Street 2:STE. 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-503-2559
Practice Address - Fax:253-503-8513
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028164207ZP0102X
AZ34168207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00028164OtherWA LICENSE
WA8250110Medicaid
WAG8861347Medicare PIN
WA8250110Medicaid
WA0001045700Medicare PIN
WAMD00028164OtherWA LICENSE
WA220028038Medicare PIN
WAP00447838Medicare PIN