Provider Demographics
NPI:1275158115
Name:KOONTZ, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:503 N 21ST ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2204
Practice Address - Country:US
Practice Address - Phone:717-531-5638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061679363A00000X
PAOA005245363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical