Provider Demographics
NPI:1962757294
Name:MURDOCK, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21654 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1336
Mailing Address - Country:US
Mailing Address - Phone:906-235-0263
Mailing Address - Fax:
Practice Address - Street 1:17500 FEDERAL DR
Practice Address - Street 2:STE 750
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-3652
Practice Address - Country:US
Practice Address - Phone:313-982-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant