Provider Demographics
NPI:1881259653
Name:KELLEY, JOHN PAUL JR (PA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PAUL
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23555 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-3232
Mailing Address - Country:US
Mailing Address - Phone:240-434-6104
Mailing Address - Fax:
Practice Address - Street 1:1130 ANNAPOLIS RD STE 100
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1622
Practice Address - Country:US
Practice Address - Phone:410-672-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant