Provider Demographics
NPI:1881096311
Name:KELLY, BRENNAN L (PAC)
Entity type:Individual
Prefix:
First Name:BRENNAN
Middle Name:L
Last Name:KELLY
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3700 SOUTHERN BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1226
Mailing Address - Country:US
Mailing Address - Phone:937-643-9299
Mailing Address - Fax:937-643-2343
Practice Address - Street 1:3700 SOUTHERN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1226
Practice Address - Country:US
Practice Address - Phone:937-643-9299
Practice Address - Fax:937-643-2343
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50004106363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110411Medicaid
OHH396970Medicare PIN