Provider Demographics
NPI:1831904317
Name:KELLEY, PATRICK MAYO
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:MAYO
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 LEESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCH STATION
Mailing Address - State:VA
Mailing Address - Zip Code:24571-3110
Mailing Address - Country:US
Mailing Address - Phone:804-577-3968
Mailing Address - Fax:
Practice Address - Street 1:1465 LEESVILLE RD
Practice Address - Street 2:
Practice Address - City:LYNCH STATION
Practice Address - State:VA
Practice Address - Zip Code:24571-3110
Practice Address - Country:US
Practice Address - Phone:804-577-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110010678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant