MEDICARE: JOHN S KELLEY PAC

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	363A00000X	Physician Assistant	641	OK

General Provider Information

NPI Number	:	1568454098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN S KELLEY PAC

Provider Business Mailing Address
First Line	:	3400 E FRANK PHILLIPS BLVD
Second Line	:	SUITE 602
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-2495
Country	:	US
Telephone Number	:	918-331-2440
Fax Number	:	918-331-2433

Provider Business Practice Location Address
First Line	:	3400 E FRANK PHILLIPS BLVD
Second Line	:	SUITE 602
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-2495
Country	:	US
Telephone Number	:	918-331-2440
Fax Number	:	918-331-2433

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	07/08/2007

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Directions to “ JOHN S KELLEY PAC” Practice Location

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