Provider Demographics
NPI:1194963421
Name:MCCLURE, KELLY JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JAMES
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3323
Mailing Address - Country:US
Mailing Address - Phone:619-861-9672
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-8859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant