Provider Demographics
NPI:1194915496
Name:PHILLIPS, KELLY SHADMAN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SHADMAN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 OLD MILTON PKWY # C
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3707
Mailing Address - Country:US
Mailing Address - Phone:770-667-4337
Mailing Address - Fax:770-667-4338
Practice Address - Street 1:1505 NORTHSIDE FORSYTH BLVD
Practice Address - Street 2:STE 3500
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-292-6500
Practice Address - Fax:770-292-6535
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03244363A00000X
TN1512363A00000X, 363AM0700X
TNPA0000001512363AS0400X
GA007088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003144287FMedicaid
GA003144287HMedicaid
GA003144287EMedicaid
TN103I086169Medicare UPIN
GA003144287EMedicaid
GA202I979732Medicare PIN
TN36650861Medicare PIN