| Provider / Organization | NPI | Date Certified |
|---|---|---|
| RANDALL DOUGLAS KELLY | 1922393974 | 2011-06-16 |
Randall Douglas Kelly is registered with the National Plan and Provider Enumeration System and has been issued an National Provider Identifier (NPI) of 1922393974. Registration indicates Randall Douglas Kelly is a provider of services with a specialization in Preventive Medicine Addiction Medicine, Allopathic & Osteopathic Physicians (Preventive Medicine Addiction Medicine, Allopathic & Osteopathic Physicians) Access to Adult/Geriatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers) Access to Adult/Geriatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers)
| Registration | PART-B:Y DME:Y HHA:Y PMD:Y |
| Entity Type | Individual |
| Provider Name | Mr. Randall Douglas Kelly PA-C, DMSC |
| Practice Office Address | 256 E HURLBURT AVE STE 117 HERMISTON, OR US |
| Practice Office Telephone | 5413519150 |
| Practice Office Fax | 5095934644 |
| Mailing Address | 5426 ROAD 68 STE D253 PASCO, WA 993015268 US |
| Business Telephone | 5413519150 |
| Business Fax | 5095934644 |
| Address | City / State | Phone / Fax |
|---|---|---|
| 1500 W Court St | Pasco, WA 993014057 | 5092221275 / 5094913031 |
| 4909 S Coast Hwy Ste 1K | South Beach, OR 973669667 | 5413519150 / 5095934644 |
| 114 E 16th Ave | Eugene, OR 974014033 | 5417902455 / 5417902423 |
| 84934 Winesap Rd | Milton Freewater, OR 978627361 | 5413519150 / 5095934644 |
| 145 N Coast Hwy Ste B | Newport, OR 973653165 | 5413519150 / 5095934644 |
| 74 E 18th Ave | Eugene, OR 974014081 | 5413519150 / 5095934644 |
| 32405 Diagonal Rd | Hermiston, OR 978387503 | 5413519150 / 5095934644 |
| 1817 NE 6th Ave | Portland, OR 972123960 | 5413519150 / 5095934644 |
| 5601 Concord Dr | Pasco, WA 993015462 | 2064188222 / 5095934644 |
| 124 W Kennewick Ave Ste 9 | Kennewick, WA 993363830 | 5413519150 / 5095934644 |
| 160 E 18th Ave | Eugene, OR 974014160 | 2064188222 / 5417902423 |
| Code | Practice | License No State |
|---|---|---|
| 2083A0300X | Preventive Medicine Addiction Medicine Allopathic & Osteopathic Physicians | PA60205772
WA |
| 2083A0300X | Preventive Medicine Addiction Medicine Allopathic & Osteopathic Physicians | PA184529
OR |
| 363A00000X | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers | PA60205772
WA |
| 363A00000X PRIMARY | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers | PA184529
OR |
| 0281857 | OTHER | WA | LABOR & INDUSTR |
| 2013576 | MEDICAID | WA |