Provider Demographics
NPI:1205884863
Name:KELLEY, DEBORAH A (PAC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:A
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:218 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:TX
Mailing Address - Zip Code:75163-6060
Mailing Address - Country:US
Mailing Address - Phone:903-778-2942
Mailing Address - Fax:
Practice Address - Street 1:218 PARK ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:TX
Practice Address - Zip Code:75163-6060
Practice Address - Country:US
Practice Address - Phone:903-778-2942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1266-023363A00000X
TXPA08061363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP79183Medicare UPIN