| Doctor Name: | MR. JONATHAN D KELLY |
| NPI Number: | 1053529446 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA.C. |
| License Number: | PA054 |
| Business Practice Address: | 102 Llano St Aztec, NM - 874102172 |
| Business Phone Number: | 5053349441 |
| Business Fax Number: | 5053348750 |
| Mailing Address: | 102 Llano St, AZTEC |
| State: | NM |
| Postal Code: | 87410 |
| Phone Number: | 5053349441 |
| Fax Number: | 5053348750 |
| NPI Enumeration Date: | 05/18/2007 |
| NPI Last Update Date: | 08/20/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | PA054 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |