Provider Demographics
NPI:1306942099
Name:GERGELY, KELLY A (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GERGELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SCHUYLKILL HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17972-9779
Mailing Address - Country:US
Mailing Address - Phone:570-366-3063
Mailing Address - Fax:
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4143
Practice Address - Fax:570-621-4769
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003110L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096914MK6Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER