Healthcare Provider Details

I. General information

NPI: 1629193065
Provider Name (Legal Business Name): JAMES PAUL KELLEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GREATSTONE PT
LEXINGTON KY
40504-3274
US

IV. Provider business mailing address

138 LEADER AVE
LEXINGTON KY
40508-3215
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-5150
  • Fax: 859-257-8675
Mailing address:
  • Phone: 859-257-7910
  • Fax: 859-257-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA058
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: