Provider Demographics
NPI:1891974218
Name:KELLY, ADAM CHRISTOPHER (PA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:CHRISTOPHER
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:36500 AURORA DR
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS- NICU
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4899
Mailing Address - Country:US
Mailing Address - Phone:262-434-4900
Mailing Address - Fax:262-434-4901
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS- NEONATAL ICU
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-4900
Practice Address - Fax:262-434-4901
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2021-11-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI2363-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2363-23OtherWISCONSIN LICENSE