Provider Demographics
NPI:1629552625
Name:ELLENDER-BARTHEL, KELSEY AUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:AUSTIN
Last Name:ELLENDER-BARTHEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2326
Mailing Address - Country:US
Mailing Address - Phone:318-212-3369
Mailing Address - Fax:
Practice Address - Street 1:8001 YOUREE DR STE 350
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2326
Practice Address - Country:US
Practice Address - Phone:318-212-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPENDINGMedicaid