Healthcare Provider Details

I. General information

NPI: 1073571816
Provider Name (Legal Business Name): MICHAEL TIMOTHY KELLEY M.S. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 S RURAL RD STE 104
TEMPE AZ
85283-3717
US

IV. Provider business mailing address

2532 E MERCER LN
PHOENIX AZ
85028-2530
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-4515
  • Fax: 480-833-5078
Mailing address:
  • Phone: 602-799-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberAZ3829
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: