Individual
MARTIN J. KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
263 FARMINGTON AVE, PROVIDER ENROLLMENT, FARMINGTON, CT 06030-2212
(860) 679-7503
(860) 679-1610
Mailing address
263 FARMINGTON AVE, PROVIDER ENROLLMENT, FARMINGTON, CT 06030-2212
(860) 679-7503
(860) 679-1610
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
000979
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000979
PA LICENSE
CT
05
—
003009792
—
CT
01
—
30656
CONTROLLED SUBSTANCE LIC
CT
Enumeration date
01/11/2007
Last updated
03/07/2023
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