Provider Demographics
NPI:1740366111
Name:KELLY, MICHAEL JOSEPH JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3361
Mailing Address - Country:US
Mailing Address - Phone:918-488-6653
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:6585 S YALE AVE STE 720
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8320
Practice Address - Country:US
Practice Address - Phone:918-502-5930
Practice Address - Fax:918-502-5935
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4618363A00000X
CO2567363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC811714Medicare PIN