Provider Demographics
NPI:1740702927
Name:OLSEN, KELLY ELISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELISE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELISE
Other - Last Name:LAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7304
Mailing Address - Country:US
Mailing Address - Phone:817-250-4280
Mailing Address - Fax:817-250-4281
Practice Address - Street 1:800 5TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7304
Practice Address - Country:US
Practice Address - Phone:817-250-4280
Practice Address - Fax:817-250-4281
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12627363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical