Healthcare Provider Details

I. General information

NPI: 1972790707
Provider Name (Legal Business Name): PAUL GERARD KELLY MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE 5TH ST
GRESHAM OR
97030-7345
US

IV. Provider business mailing address

25117 SW PARKWAY AVE STE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5600
  • Fax:
Mailing address:
  • Phone: 503-570-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2945
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: