Provider Demographics
NPI:1972054708
Name:WHITE, KELSEY S (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:S
Last Name:WHITE
Suffix:
Gender:
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:B1321
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-3300
Practice Address - Fax:317-217-3474
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002139A363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430B03OtherMEDICARE PTAN
INP02386895OtherRAILROAD PTAN
IN300013802Medicaid
IN068010336OtherMEDICARE PTAN
IN267030268OtherMEDICARE PTAN