Provider Demographics
NPI:1881654697
Name:KELLEY, KEVIN F SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:F
Last Name:KELLEY
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:111 STRAUSS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-1524
Mailing Address - Country:US
Mailing Address - Phone:301-744-1004
Mailing Address - Fax:301-744-1028
Practice Address - Street 1:101 STRAUSS AVE
Practice Address - Street 2:CBIRF, 2ND MEF
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-1542
Practice Address - Country:US
Practice Address - Phone:301-744-1004
Practice Address - Fax:301-744-1028
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110840675363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical