Provider Demographics
NPI:1740966449
Name:THAYER, KELSEY NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:THAYER
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 1:5 DARYL AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-1947
Mailing Address - Country:US
Mailing Address - Phone:415-320-0916
Mailing Address - Fax:
Practice Address - Street 1:1111 SONOMA AVE STE 210
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4833
Practice Address - Country:US
Practice Address - Phone:707-324-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant