Healthcare Provider Details

I. General information

NPI: 1407942097
Provider Name (Legal Business Name): ROSEMARIE KELLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE DOCTOR'S MEDICAL CENTER - NEURO ICU
MODESTO CA
95350-4405
US

IV. Provider business mailing address

1441 FLORIDA AVE GREATER MODESTO MEDICAL SURGICAL ASSOCIATES
MODESTO CA
95350-4404
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3872
  • Fax:
Mailing address:
  • Phone: 209-576-3601
  • Fax: 209-576-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13565
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA13565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: