Provider Demographics
NPI:1053529446
Name:KELLY, JONATHAN D (PAC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:622 W MAPLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6589
Mailing Address - Country:US
Mailing Address - Phone:505-327-4867
Mailing Address - Fax:505-327-5355
Practice Address - Street 1:622 W MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6589
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical