Healthcare Provider Details

I. General information

NPI: 1841573805
Provider Name (Legal Business Name): BOBBY CHAD KELLETT P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 EXPERIMENT STATION RD # 505
WATKINSVILLE GA
30677
US

IV. Provider business mailing address

1230 BAXTER ST
ATHENS GA
30606-3712
US

V. Phone/Fax

Practice location:
  • Phone: 706-310-0324
  • Fax:
Mailing address:
  • Phone: 404-392-3548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7603
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2019
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: