Provider Demographics
NPI:1427867704
Name:PORTER, KELSEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:PORTER
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 1:1880 MALVERN ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5130
Mailing Address - Country:US
Mailing Address - Phone:651-403-3506
Mailing Address - Fax:
Practice Address - Street 1:375 NEWTON ROAD
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:651-403-3506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant