Provider Demographics
NPI:1720409824
Name:KELLY, PATRICK JOHN (PA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3854 NIAMI ST
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3543
Mailing Address - Country:US
Mailing Address - Phone:516-477-8325
Mailing Address - Fax:
Practice Address - Street 1:3318 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1806
Practice Address - Country:US
Practice Address - Phone:718-204-7550
Practice Address - Fax:718-204-7566
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYP91199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant