Provider Demographics
NPI:1174150387
Name:WALLS, KELSEY TAYLOR (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:TAYLOR
Last Name:WALLS
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 1:89 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417-1509
Mailing Address - Country:US
Mailing Address - Phone:951-205-8570
Mailing Address - Fax:
Practice Address - Street 1:89 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:NY
Practice Address - Zip Code:13417-1509
Practice Address - Country:US
Practice Address - Phone:951-205-8570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant