Provider Demographics
NPI:1164041059
Name:HAGAN, KELSEY LOUISE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LOUISE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 BURNS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4627
Mailing Address - Country:US
Mailing Address - Phone:561-694-7776
Mailing Address - Fax:561-694-3099
Practice Address - Street 1:4215 BURNS RD STE 100
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4627
Practice Address - Country:US
Practice Address - Phone:561-694-7776
Practice Address - Fax:561-694-3099
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112977363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254016972Medicaid