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NPI Code Detail

MEDICARE: PHILLIP ANTONIO KELLEY PA-C

MEDICARE: PHILLIP ANTONIO KELLEY PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0010-04383NC

General Provider Information

NPI Number : 1083055396
Entity Type Code : Individual
Provider Name (Legal Business Name) : PHILLIP ANTONIO KELLEY PA-C
Provider Business Mailing Address
First Line : PO BOX 60447
Second Line :
City : CHARLOTTE
State : NC
Zip : 28260-0447
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 390 W SALEM AVE
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27101-5861
Country : US
Telephone Number : 336-721-2375
Fax Number : 336-721-2394
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/15/2013
Last Update Date : 07/18/2022

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Directions to “ PHILLIP ANTONIO KELLEY PA-C” Practice Location

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