Provider Demographics
NPI:1629154240
Name:KELLY, ANTHONY MARTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MARTIN
Last Name:KELLY
Suffix:
Gender:M
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 1:471 AINSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4105
Mailing Address - Country:US
Mailing Address - Phone:530-751-9355
Mailing Address - Fax:530-751-9122
Practice Address - Street 1:471 AINSLEY AVE
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4105
Practice Address - Country:US
Practice Address - Phone:530-751-9355
Practice Address - Fax:530-751-9122
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA130230Medicare ID - Type Unspecified
CAP53253Medicare UPIN