Provider Demographics
NPI:1285170738
Name:KELLY, SEAN (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4624 N SPIDER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8440
Mailing Address - Country:US
Mailing Address - Phone:231-947-0673
Mailing Address - Fax:801-740-2847
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:801-740-2847
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2021-03-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008056OtherLICENSE