Provider Demographics
NPI:1366951253
Name:GLIDEWELL, KELSEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PHR GROUP PROVIDER ENROLLMENT UNIT
Mailing Address - Street 2:393 E WALNUT ST FL 3
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-24
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA54919363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical