Provider Demographics
NPI:1619948064
Name:KELM, COURTNEY G (PAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:G
Last Name:KELM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:G
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20280 N 59TH AVE
Mailing Address - Street 2:STE 115-617
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:602-795-8700
Mailing Address - Fax:602-795-8701
Practice Address - Street 1:725 S DOBSON RD
Practice Address - Street 2:STE 100
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5680
Practice Address - Country:US
Practice Address - Phone:602-795-8700
Practice Address - Fax:602-795-8701
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2515363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ623307Medicaid
AZ623307Medicaid
AZ67415Medicare ID - Type Unspecified