Provider Demographics
NPI:1679967749
Name:ANDERSON, KELSEY JEAN (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JEAN
Last Name:ANDERSON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-564-4950
Mailing Address - Fax:336-564-4959
Practice Address - Street 1:1730 KERNERSVILLE MEDICAL PKWY STE 101
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7198
Practice Address - Country:US
Practice Address - Phone:336-564-4950
Practice Address - Fax:336-564-4959
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA2325363A00000X
NC0010-11902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2508PAMedicaid
SC8029OtherMEDICARE GROUP
SCGP3980OtherMEDICAID GROUP
SC2508PAMedicaid