Provider Demographics
NPI:1386750966
Name:KELLEY, DOYLE W (PA)
Entity type:Individual
Prefix:
First Name:DOYLE
Middle Name:W
Last Name:KELLEY
Suffix:
Gender:M
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:PO BOX 547
Mailing Address - Street 2:377 NE DORNING ST.
Mailing Address - City:YACHATS
Mailing Address - State:OR
Mailing Address - Zip Code:97498-0547
Mailing Address - Country:US
Mailing Address - Phone:541-547-3933
Mailing Address - Fax:
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-696-4061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant