Provider Demographics
NPI:1013285386
Name:KELLEY, MICHAEL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KELLEY
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 1:297 NORTH ST STE 221
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5133
Mailing Address - Country:US
Mailing Address - Phone:508-862-7777
Mailing Address - Fax:
Practice Address - Street 1:1 TROWBRIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-3660
Practice Address - Country:US
Practice Address - Phone:508-778-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000737363A00000X
MAPA4403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant