Healthcare Provider Details

I. General information

NPI: 1679894133
Provider Name (Legal Business Name): KELLY JAMES REMY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 LINDERSON WAY SW CEDAR CREEK CORRECTIONS - (RURAL ADDRESS NOT RECOGNIZED
TUMWATER WA
98501-6504
US

IV. Provider business mailing address

PO BOX 37 12200 BORDEAUX ROAD
LITTLEROCK WA
98556-0037
US

V. Phone/Fax

Practice location:
  • Phone: 360-359-4070
  • Fax:
Mailing address:
  • Phone: 360-359-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 10003612
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: