Provider Demographics
NPI:1649514811
Name:ELSNER, KEITH STACY (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:STACY
Last Name:ELSNER
Suffix:
Gender:M
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 1:230 W WASHINGTON SQ STE 102
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3500
Mailing Address - Country:US
Mailing Address - Phone:215-829-3985
Mailing Address - Fax:215-829-3340
Practice Address - Street 1:230 W WASHINGTON SQ STE 102
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3500
Practice Address - Country:US
Practice Address - Phone:215-829-3985
Practice Address - Fax:215-829-3340
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000851363A00000X
PAMA055901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant