Provider Demographics
NPI:1194122002
Name:PEARSON, KELSEY (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:PEARSON
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:773-318-8243
Mailing Address - Fax:
Practice Address - Street 1:751 NE BLAKELY DR
Practice Address - Street 2:STE 4020
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6201
Practice Address - Country:US
Practice Address - Phone:425-313-7124
Practice Address - Fax:425-313-7072
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005626363A00000X
WAPA60644257363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1194122002OtherNPI