Provider Demographics
NPI:1821016890
Name:BIRT, KELLY DEAN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DEAN
Last Name:BIRT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NATIONWIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4272
Mailing Address - Country:US
Mailing Address - Phone:434-237-4004
Mailing Address - Fax:434-237-4450
Practice Address - Street 1:113 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4272
Practice Address - Country:US
Practice Address - Phone:434-237-4004
Practice Address - Fax:434-237-4450
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P32726Medicare UPIN