MEDICARE: MR. KELLY JOHN SKIPPER SURGICAL ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	09-262	TX

General Provider Information

NPI Number	:	1154654507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY JOHN SKIPPER SURGICAL ASSISTANT

Provider Business Mailing Address
First Line	:	4525 GILBERT AVE
Second Line	:	#107
City	:	DALLAS
State	:	TX
Zip	:	75219-2122
Country	:	US
Telephone Number	:	214-529-5024
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 GILBERT AVE
Second Line	:	#107
City	:	DALLAS
State	:	TX
Zip	:	75219-2122
Country	:	US
Telephone Number	:	214-529-5024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	09/16/2009

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