Provider Demographics
NPI:1659905156
Name:JEW-GARCIA, KELLY CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CHRISTINE
Last Name:JEW-GARCIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CHRISTINE
Other - Last Name:JEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6509 WISTERIA TRCE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6019
Mailing Address - Country:US
Mailing Address - Phone:310-717-7925
Mailing Address - Fax:
Practice Address - Street 1:41424 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-8005
Practice Address - Country:US
Practice Address - Phone:734-254-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57791363A00000X
MI5601010584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA57791OtherPA BOARD OF CALIFORNIA
MI5601010584OtherMICHIGAN TASK FORCE ON PHYSICIANS ASSISTANTS
MI5315227043OtherMICHIGAN TASK FORCE CONTROLLED SUBSTANCE LICENSE