Provider Demographics
NPI:1366041402
Name:KELLY, DILLON MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:DILLON
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 TURKEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8001
Mailing Address - Country:US
Mailing Address - Phone:407-351-8587
Mailing Address - Fax:
Practice Address - Street 1:9400 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:407-351-8587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115478363A00000X
LA324554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant