Provider Demographics
NPI:1679654057
Name:KELLEY, TIMOTHY P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:P
Last Name:KELLEY
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 1:202 WILLIAMSON RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7610
Mailing Address - Country:US
Mailing Address - Phone:704-799-7811
Mailing Address - Fax:704-799-7812
Practice Address - Street 1:202 WILLIAMSON RD STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7610
Practice Address - Country:US
Practice Address - Phone:704-799-7811
Practice Address - Fax:704-799-7812
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1679654057Medicaid
NC8101237Medicaid
IL085001277Medicaid
NC8101237Medicaid
NC2770891LMedicare PIN
NC2770891JMedicare PIN
NC2770891EMedicare PIN
NC2770891GMedicare PIN
NC2770891CMedicare PIN
NC2770891QMedicare PIN
IL085001277Medicaid
NC2770891DMedicare PIN
NC2770891PMedicare PIN
NC2770891SMedicare PIN
NC1679654057Medicaid
NC2770891HMedicare PIN
NC2770891KMedicare PIN
NC2770891NMedicare PIN
NC2770891BMedicare PIN
NC2770891MMedicare PIN
NC2770891RMedicare PIN
ILK10207Medicare PIN