Provider Demographics
NPI:1669545356
Name:KELLEY, ALICIA PETICOLAS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:PETICOLAS
Last Name:KELLEY
Suffix:
Gender:F
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 1:3 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2342
Mailing Address - Country:US
Mailing Address - Phone:978-897-1536
Mailing Address - Fax:
Practice Address - Street 1:15 FRANCIS STREET
Practice Address - Street 2:PBB-B4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA363A00000X363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKE AP2302Medicare ID - Type UnspecifiedPART B PROVIDER NUMBER