Provider Demographics
NPI:1710437140
Name:JEWELL, KELSEY (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JEWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:KORP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1489 S HIGLEY RD
Mailing Address - Street 2:101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4776
Mailing Address - Country:US
Mailing Address - Phone:480-457-8800
Mailing Address - Fax:480-457-8885
Practice Address - Street 1:1489 S HIGLEY RD
Practice Address - Street 2:101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296
Practice Address - Country:US
Practice Address - Phone:480-457-8800
Practice Address - Fax:480-457-8885
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6460363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ206469Medicaid