Provider Demographics
NPI:1902039514
Name:KELLEY, JUSTIN PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PATRICK
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2102 BAPTISTE DR
Mailing Address - Street 2:SUITE # E
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1314
Mailing Address - Country:US
Mailing Address - Phone:913-557-3800
Mailing Address - Fax:913-557-5989
Practice Address - Street 1:2102 BAPTISTE DR
Practice Address - Street 2:SUITE # E
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1314
Practice Address - Country:US
Practice Address - Phone:913-557-3800
Practice Address - Fax:913-557-5989
Is Sole Proprietor?:No
Enumeration Date:2009-08-30
Last Update Date:2009-08-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS02589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant