Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 000E23210 | CA |
Y | 222Z00000X | Podiatrist | 000E23210 | CA |
N | 111NR0200X | Radiology | 000E23210 | CA |
N | 213ER0200X | Radiology | 000E23210 | CA |
N | 213ES0103X | Foot & Ankle Surgery | 000E23210 | CA |
NPI | 1437184025 |
---|---|
Provider Name | Neil R Kelley |
First Address | Fortuna, CA 95540-2451 |
Second Address | Fortuna, CA 95540-2451 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 27/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201857499 | BLUE CROSS (01) | CA |
GRE001770 | (05) | CA |
T11285 | (02) | CA |
ZZZ64278Z | BLUE SHIELD (01) | CA |