Provider Demographics
NPI:1306807979
Name:MCQUEEN, KELLY G (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:276 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24263-1215
Mailing Address - Country:US
Mailing Address - Phone:423-224-3900
Mailing Address - Fax:423-224-3901
Practice Address - Street 1:2204 PAVILION DR
Practice Address - Street 2:SUITE 310
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4657
Practice Address - Country:US
Practice Address - Phone:423-224-3900
Practice Address - Fax:423-224-3901
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203973207Q00000X
TN1209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1306807979Medicaid
TN1509015Medicaid
TNP00878625OtherRAILROAD MEDICARE
TN103I126291Medicare PIN
TN3709285Medicare UPIN