Provider Demographics
NPI:1770031403
Name:KOCMOUD, KELSI MADELYN (PA-C)
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:MADELYN
Last Name:KOCMOUD
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Gender:F
Credentials:PA-C
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5995 N 78TH ST UNIT 2008
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-6123
Mailing Address - Country:US
Mailing Address - Phone:623-414-1246
Mailing Address - Fax:
Practice Address - Street 1:13943 N 91ST AVE STE B101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3688
Practice Address - Country:US
Practice Address - Phone:623-476-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-09-17
Deactivation Date:
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Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer