Provider Demographics
NPI:1073980728
Name:NORTH, KELSEY A (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:NORTH
Suffix:
Gender:F
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 1:971 LAKELAND DR STE 1460
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4621
Mailing Address - Country:US
Mailing Address - Phone:513-708-4211
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 1460
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4621
Practice Address - Country:US
Practice Address - Phone:513-708-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2047363A00000X
MS00337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN