Provider Demographics
NPI:1912333840
Name:COLSON, KENESHA PATRICE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KENESHA
Middle Name:PATRICE
Last Name:COLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KENESHA
Other - Middle Name:PATRICE
Other - Last Name:MCGRUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-633-7245
Mailing Address - Fax:
Practice Address - Street 1:326 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5156
Practice Address - Country:US
Practice Address - Phone:760-633-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant