Provider Demographics
NPI:1669954269
Name:SITAR, KELSEY LYNN (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:SITAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:L
Other - Last Name:KOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:3975 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3901
Mailing Address - Country:US
Mailing Address - Phone:951-352-2092
Mailing Address - Fax:
Practice Address - Street 1:3975 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3901
Practice Address - Country:US
Practice Address - Phone:951-352-2092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56109OtherMEDICAL LICENSE