Provider Demographics
NPI:1669428876
Name:CLINTON, KELLY A (PAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:CLINTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5445 CARUTH HAVEN LN
Mailing Address - Street 2:APT 924
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-8143
Mailing Address - Country:US
Mailing Address - Phone:214-797-7947
Mailing Address - Fax:
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:SUITE 225
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:972-599-2559
Practice Address - Fax:972-599-1226
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280826302Medicaid
TX8Y0105OtherBCBS
TX280826303Medicaid
TX1067023OtherNCCPA
TXP01057828OtherRAILROAD MEDICARE
TX280826301Medicaid