Healthcare Provider Details

I. General information

NPI: 1649388935
Provider Name (Legal Business Name): KELLY DUEWER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY BURGESS PA

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3404 WAKE FOREST RD # ROD
RALEIGH NC
27609-7340
US

IV. Provider business mailing address

3404 WAKE FOREST RD
RALEIGH NC
27609-7340
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5480
  • Fax: 919-862-5483
Mailing address:
  • Phone: 919-862-5480
  • Fax: 919-862-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number011430
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01632
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: