Provider Demographics
NPI:1861044612
Name:MURTHA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MURTHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3105
Mailing Address - Country:US
Mailing Address - Phone:631-669-2555
Mailing Address - Fax:
Practice Address - Street 1:540 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3105
Practice Address - Country:US
Practice Address - Phone:631-669-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant