Provider Demographics
NPI:1821177130
Name:NORTH, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:NORTH
Suffix:
Gender:F
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 1:260 TOWNSHIP BLVD
Mailing Address - Street 2:STE 20
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1678
Mailing Address - Country:US
Mailing Address - Phone:315-708-0091
Mailing Address - Fax:315-708-0194
Practice Address - Street 1:260 TOWNSHIP BLVD
Practice Address - Street 2:STE 20
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1678
Practice Address - Country:US
Practice Address - Phone:315-708-0091
Practice Address - Fax:315-708-0194
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001686L363AM0700X
PAOA002604363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ65179Medicare UPIN
PA098948HYLMedicare ID - Type Unspecified