Healthcare Provider Details

I. General information

NPI: 1053529446
Provider Name (Legal Business Name): JONATHAN D KELLY PA.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W MAPLE ST STE B
FARMINGTON NM
87401-6589
US

IV. Provider business mailing address

622 W MAPLE ST STE B
FARMINGTON NM
87401-6589
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4867
  • Fax:
Mailing address:
  • Phone: 505-327-4867
  • Fax: 505-327-5355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA054
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: