Provider Demographics
NPI:1699982298
Name:LUPO, KELLY J (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:LUPO
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:3621 SOUTH STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP 'G'
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5338
Practice Address - Country:US
Practice Address - Phone:734-936-7010
Practice Address - Fax:734-936-9294
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-01-07
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Provider Licenses
StateLicense IDTaxonomies
MI5601003533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant