Provider Demographics
NPI:1851575476
Name:KELLY, MARTIN J (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0507
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-0979
Practice Address - Street 1:2710 RIFE MEDICAL LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:913-642-4900
Practice Address - Fax:913-381-0979
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC002728367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00849069OtherRR
AR176438001Medicaid
AR5V105OtherBCBS
AR604337200OtherDOL
AR176438001Medicaid