Provider Demographics
NPI:1083853162
Name:KORTAN, CHELSEY M (PA-C)
Entity Type:Individual
Prefix:
First Name:CHELSEY
Middle Name:M
Last Name:KORTAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHELSEY
Other - Middle Name:M
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:STE G01
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4647
Practice Address - Country:US
Practice Address - Phone:605-328-2663
Practice Address - Fax:605-328-3760
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS103168Medicare PIN