1093856247 NPI number — MRS. KELLY ALLISON MCMILLAN PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093856247 NPI number — MRS. KELLY ALLISON MCMILLAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMILLAN
Provider First Name:
KELLY
Provider Middle Name:
ALLISON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093856247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3682 E SUNNYDALE DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
QUEEN CREEK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85142-7368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-882-9993
Provider Business Mailing Address Fax Number:
480-248-2377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
287 E HUNT HWY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85143-5096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-677-8282
Provider Business Practice Location Address Fax Number:
480-677-8283
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  3594 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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