Provider Demographics
NPI:1881932481
Name:WEITZ, KELLY (MS, PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WEITZ
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:984-215-4111
Mailing Address - Fax:
Practice Address - Street 1:219 OBERLIN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1646
Practice Address - Country:US
Practice Address - Phone:919-882-0030
Practice Address - Fax:919-882-0031
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04026363AM0700X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical