Provider Demographics
NPI:1922393974
Name:KELLY, RANDALL DOUGLAS (PA-C, DMSC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DOUGLAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 ROAD 68 STE D253
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5268
Mailing Address - Country:US
Mailing Address - Phone:541-351-9150
Mailing Address - Fax:509-593-4644
Practice Address - Street 1:256 E HURLBURT AVE STE 117
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2443
Practice Address - Country:US
Practice Address - Phone:541-351-9150
Practice Address - Fax:509-593-4644
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA602057722083A0300X, 363A00000X
ORPA1845292083A0300X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0281857OtherLABOR & INDUSTRIES
WA2013576Medicaid
WA0281857OtherLABOR & INDUSTRIES
WA8901854Medicare PIN
WAG8934094Medicare PIN
WA2013576Medicaid
WAG8934091Medicare PIN