Basic Information
| Provider Information | |||||||||
| NPI: | 1073664793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | GEORGIE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 POTTERY AVE | ||||||||
| Address2: | PORT ORCHARD MEDICAL CENTER | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608955000 | ||||||||
| FaxNumber: | 3608955034 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533836120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10003604 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8399370 | 05 | WA | MEDICAID |