Provider Demographics
NPI:1851380471
Name:KELLY, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:215-442-5085
Mailing Address - Fax:877-329-2370
Practice Address - Street 1:250 S 21ST ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3851
Practice Address - Country:US
Practice Address - Phone:610-250-4303
Practice Address - Fax:610-250-4846
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN316546L367500000X
NJ26NJ00335100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075242OtherAANA ID
PAP00678819OtherRAILROAD MEDICARE
NJ26NR08257400OtherREGISTERED PROF NURSE
PA101495676Medicaid
PA102605Medicare PIN