Provider Demographics
NPI:1629590187
Name:WHEELER, KELLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
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 1:310 BAKER AVE STE 175D
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2140
Mailing Address - Country:US
Mailing Address - Phone:978-287-3835
Mailing Address - Fax:
Practice Address - Street 1:133 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4169
Practice Address - Country:US
Practice Address - Phone:978-369-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-16
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant