Healthcare Provider Details

I. General information

NPI: 1073595104
Provider Name (Legal Business Name): KELLY P WARD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 OGLETHORPE AVE STE 500B
ATHENS GA
30606-2184
US

IV. Provider business mailing address

1500 OGLETHORPE AVE STE 500B
ATHENS GA
30606-2184
US

V. Phone/Fax

Practice location:
  • Phone: 706-369-5440
  • Fax:
Mailing address:
  • Phone: 706-369-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003050
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: