Provider Demographics
NPI:1073950895
Name:KELZER, MATTHEW STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:KELZER
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 1:1530 NEEDMORE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-3980
Mailing Address - Country:US
Mailing Address - Phone:937-277-4274
Mailing Address - Fax:
Practice Address - Street 1:1530 NEEDMORE RD STE 300
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3980
Practice Address - Country:US
Practice Address - Phone:937-277-4274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003850RX363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096509Medicaid