Healthcare Provider Details

I. General information

NPI: 1588853899
Provider Name (Legal Business Name): CLAY BARTON KELLEY AAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

1488 JESSE JEWELL PKWY SE STE 100
GAINESVILLE GA
30501-3803
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-7179
  • Fax:
Mailing address:
  • Phone: 770-532-7179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number1648
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: