Provider Demographics
NPI:1376871426
Name:O'MARA, KELSEY CHARLOTTE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:CHARLOTTE
Last Name:O'MARA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:CHARLOTTE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-409-9925
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1333363A00000X
IN10001499A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0314133Medicaid
12060975OtherCAQH PROVIDER ID
KY1700235OtherWELLCARE OF KY PROVIDER ID NUMBER
KY7100155270Medicaid
CS1828800128OtherCARESOURCE ID
000001202435OtherANTHEM PIN
IN300018062Medicaid
98745KYIPOtherAETNA BETTER HEALTH