Provider Demographics
NPI:1952359309
Name:KELLY, CHRISTINE (PA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 CUTTERMILL RD
Practice Address - Street 2:507
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3104
Practice Address - Country:US
Practice Address - Phone:516-487-8738
Practice Address - Fax:516-487-1601
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0046731363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW5H781Medicare ID - Type Unspecified
NYP87242Medicare UPIN