Provider Demographics
NPI:1902025448
Name:FOLEY, KELLY MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHAEL
Last Name:FOLEY
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 1:305 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4157
Mailing Address - Country:US
Mailing Address - Phone:931-552-6722
Mailing Address - Fax:931-552-6979
Practice Address - Street 1:305 DOVER RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4157
Practice Address - Country:US
Practice Address - Phone:931-552-6722
Practice Address - Fax:931-552-6979
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO30055Medicare UPIN