Provider Demographics
NPI:1477950475
Name:HOLMES, KELSEY L (PAC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 COUNTY ROAD C W
Mailing Address - Street 2:250
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1352
Mailing Address - Country:US
Mailing Address - Phone:651-633-6883
Mailing Address - Fax:
Practice Address - Street 1:1835 COUNTY ROAD C W
Practice Address - Street 2:250
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1352
Practice Address - Country:US
Practice Address - Phone:651-633-6883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11711363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical