Provider Demographics
NPI:1649388935
Name:DUEWER, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DUEWER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3404 WAKE FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7340
Mailing Address - Country:US
Mailing Address - Phone:919-862-5480
Mailing Address - Fax:919-862-5483
Practice Address - Street 1:3404 WAKE FOREST RD # ROD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7340
Practice Address - Country:US
Practice Address - Phone:919-862-5480
Practice Address - Fax:919-862-5483
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011430363AS0400X
NC01632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00388622OtherMEDICARE RAILROAD
PA1535Medicare ID - Type Unspecified70008A GROUP
NYP00388622OtherMEDICARE RAILROAD
Q74396Medicare UPIN