Provider Demographics
NPI:1902956550
Name:KELLY, LARRY (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3125 POPLARWOOD CT
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1084
Mailing Address - Country:US
Mailing Address - Phone:919-832-7351
Mailing Address - Fax:
Practice Address - Street 1:2101 GARNER RD
Practice Address - Street 2:SUITE 113
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4687
Practice Address - Country:US
Practice Address - Phone:919-832-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant