Provider Demographics
NPI:1851502942
Name:KELLY, KEVIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
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 1:1643 MEADOW VIEW RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7913
Mailing Address - Country:US
Mailing Address - Phone:417-725-2135
Mailing Address - Fax:
Practice Address - Street 1:4049 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5303
Practice Address - Country:US
Practice Address - Phone:417-890-5550
Practice Address - Fax:417-889-6898
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2007009235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant