Provider Demographics
NPI:1346657962
Name:MIRABAL, KELSEY A (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:MIRABAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:A
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1312
Mailing Address - Country:US
Mailing Address - Phone:607-324-5626
Mailing Address - Fax:607-324-1374
Practice Address - Street 1:2701 CULVER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-2876
Practice Address - Country:US
Practice Address - Phone:585-266-4000
Practice Address - Fax:585-266-4004
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17693363A00000X
NY017693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant