1710437140 NPI number — KELSEY JEWELL PA

Table of content: KELSEY JEWELL PA (NPI 1710437140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710437140 NPI number — KELSEY JEWELL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEWELL
Provider First Name:
KELSEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KORP
Provider Other First Name:
KELSEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710437140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1489 S HIGLEY RD
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-4776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-457-8800
Provider Business Mailing Address Fax Number:
480-457-8885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1489 S HIGLEY RD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-457-8800
Provider Business Practice Location Address Fax Number:
480-457-8885
Provider Enumeration Date:
10/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  6460 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 6460 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206469 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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