Basic Information
| Provider Information | |||||||||
| NPI: | 1407942097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | ROSEMARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | GREATER MODESTO MEDICAL SURGICAL ASSOCIATES | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095763601 | ||||||||
| FaxNumber: | 2095763680 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | DOCTOR'S MEDICAL CENTER - NEURO ICU | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095763872 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13565 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA13565 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | CD069A | 01 | CA | GROUP PTAN | OTHER |