Healthcare Provider Details

I. General information

NPI: 1235781584
Provider Name (Legal Business Name): STEPHEN KELLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-5086
US

IV. Provider business mailing address

9315 WINDSOR LN NE # A202
OLYMPIA WA
98516-5953
US

V. Phone/Fax

Practice location:
  • Phone: 609-774-4071
  • Fax:
Mailing address:
  • Phone: 609-774-4071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number61188032
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: