Provider Demographics
NPI:1548692981
Name:KELLY, TUYET QUACH (PA-C)
Entity type:Individual
Prefix:
First Name:TUYET
Middle Name:QUACH
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TUYET
Other - Middle Name:SUONG
Other - Last Name:QUACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:211 E ONTARIO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3284
Mailing Address - Country:US
Mailing Address - Phone:312-694-7000
Mailing Address - Fax:312-926-6274
Practice Address - Street 1:211 E ONTARIO ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3284
Practice Address - Country:US
Practice Address - Phone:312-694-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004740363A00000X
WAPA60543645363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA366426OtherSTATE L&I