Provider Demographics
NPI:1386605913
Name:CAMPBELL, KELLY L (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:CHAPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8230 WALNUT HILL LN STE 208
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4409
Mailing Address - Country:US
Mailing Address - Phone:214-692-6135
Mailing Address - Fax:
Practice Address - Street 1:8230 WALNUT HILL LN STE 208
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4409
Practice Address - Country:US
Practice Address - Phone:214-692-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01197363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y1926OtherBLUE CROSS BLUE SHIELD
TXR80150Medicare UPIN
TX8Y1926OtherBLUE CROSS BLUE SHIELD
TX8F881Medicare PIN
TX8L10799Medicare PIN