NPIMap

Individual provider Active NPI

Jonathan D Kelly, PA.C.

  • Medical Physician Assistant
  • Farmington, NM
National Provider Identifier
1053529446
Registry record updated Jan 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
PA054 Issued in NM
Practice address
622 W Maple St Ste B
Farmington, NM 87401-6589
Phone
(505) 327-4867
NPI assigned
May 18, 2007
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X PA054 NM Primary

Addresses

Primary practice location

622 W Maple St Ste B
Farmington, NM 87401-6589

Mailing address

622 W Maple St Ste B
Farmington, NM 87401-6589
Phone (505) 327-4867

Other practice location 1

102 Llano St
Aztec, NM 87410-2172
Phone (505) 334-9441

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100922001252 NM Practitioner - Physician Assistant 7517083926 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
San Juan Medical Group PCGroup PAC ID 2264468503, 11 clinicians

Practice addresses (Care Compare)

622 W Maple St
Suite B
Farmington, NM 87401-6589
Phone 5053274867106

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA054NMMDMedical Physician Assistant

Interoperability endpoints

  • Direct secure messaging: jonathan.kelly.1@11485.direct.athenahealth.com

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179446400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1673481600000",
    "number": "1053529446",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "622 W MAPLE ST STE B",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874016589",
            "telephone_number": "505-327-4867",
            "fax_number": "505-327-5355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "622 W MAPLE ST STE B",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874016589",
            "telephone_number": "505-327-4867"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "102 Llano St",
            "address_purpose": "LOCATION",
            "city": "Aztec",
            "state": "NM",
            "postal_code": "874102172",
            "country_code": "US",
            "telephone_number": "505-334-9441",
            "fax_number": "505-334-8750",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELLY",
        "first_name": "JONATHAN",
        "middle_name": "D",
        "name_prefix": "Mr.",
        "credential": "PA.C.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-18",
        "last_updated": "2023-01-12",
        "certification_date": "2023-01-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NM",
            "license": "PA054",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Farmington, NM

Sources for this page

Verify at the official NPI Registry.