Provider Demographics
NPI:1851829964
Name:WILLIARD, KELSEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:WILLIARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:L
Other - Last Name:LAGERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1072 MARKET ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-2458
Practice Address - Country:US
Practice Address - Phone:570-286-8521
Practice Address - Fax:570-286-6197
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059097363A00000X
PAOA004178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033621040012Medicaid
PA587565F6KOtherMEDICARE