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NPI Code Detail

MEDICARE: MRS. KELLY L. STAFFORD PA-C

MEDICARE: MRS. KELLY L. STAFFORD PA-C
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
1363AS0400XSurgical Physician AssistantMA051965PA
2363A00000XPhysician Assistant0010-02443NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MA051965OTHERPAMEDICAL PHYSICIAN ASST
2PA05336OTHERTXTEXAS STATE LICENSE #

General Provider Information

NPI Number : 1184626806
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLY L. STAFFORD PA-C
Provider Business Mailing Address
First Line : 4601 PARK RD
Second Line : SUITE 200
City : CHARLOTTE
State : NC
Zip : 28209-3239
Country : US
Telephone Number : 704-323-2000
Fax Number :
Provider Business Practice Location Address
First Line : 2001 VAIL AVE
Second Line : SUITE 200
City : CHARLOTTE
State : NC
Zip : 28207-1219
Country : US
Telephone Number : 704-323-2000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/12/2005
Last Update Date : 03/21/2011

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