Individual
MR. ANDREW EDWARD KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
15707
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OPT15707
BLUE SHIELD IND PROV NO
CA
01
—
ZZZ64636Z
BLUE SHIELD GROUP NUMBER
CA
Enumeration date
07/29/2005
Last updated
07/11/2007
Update your record
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