Provider Demographics
NPI:1205443991
Name:MENDEZ, KELSEY (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BASKET OAK DR
Mailing Address - Street 2:
Mailing Address - City:BUNNLEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28323-9141
Mailing Address - Country:US
Mailing Address - Phone:954-593-2411
Mailing Address - Fax:
Practice Address - Street 1:105 BASKET OAK DR
Practice Address - Street 2:
Practice Address - City:BUNNLEVEL
Practice Address - State:NC
Practice Address - Zip Code:28323-9141
Practice Address - Country:US
Practice Address - Phone:954-593-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-26
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty