Provider Demographics
NPI:1538575766
Name:KELLY, CRISTIN MAURA (PA-C)
Entity type:Individual
Prefix:
First Name:CRISTIN
Middle Name:MAURA
Last Name:KELLY
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 1:136 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-2313
Mailing Address - Country:US
Mailing Address - Phone:973-300-0555
Mailing Address - Fax:
Practice Address - Street 1:390 ROUTE 10 W
Practice Address - Street 2:SUITE 102
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2141
Practice Address - Country:US
Practice Address - Phone:973-366-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00337900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical