Provider Demographics
NPI:1871164533
Name:KELLY, STEWART CRAIG (PA-C)
Entity type:Individual
Prefix:
First Name:STEWART
Middle Name:CRAIG
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1919 STATE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-6802
Mailing Address - Country:US
Mailing Address - Phone:812-949-5933
Mailing Address - Fax:812-949-5923
Practice Address - Street 1:1919 STATE ST STE 104
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6802
Practice Address - Country:US
Practice Address - Phone:812-949-5933
Practice Address - Fax:812-949-5923
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYTC085363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant