Provider Demographics
NPI:1043316532
Name:KELLY, RUSSELL AARON (PA-C)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:AARON
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:10 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1945
Mailing Address - Country:US
Mailing Address - Phone:817-249-6671
Mailing Address - Fax:978-767-4757
Practice Address - Street 1:451 ANDOVER ST STE 206A
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5044
Practice Address - Country:US
Practice Address - Phone:978-662-1002
Practice Address - Fax:978-767-4757
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2025-08-25
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Provider Licenses
StateLicense IDTaxonomies
MA1762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111477Medicaid
MA0009706OtherMEDICARE PTAN