Provider Demographics
NPI:1760850853
Name:KELLEY, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6195
Mailing Address - Fax:
Practice Address - Street 1:987400 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-7400
Practice Address - Country:US
Practice Address - Phone:402-559-7000
Practice Address - Fax:402-559-7592
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant