Provider Demographics
NPI:1972233641
Name:LAGRUE, KELSEY A (MSPAS PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:LAGRUE
Suffix:
Gender:F
Credentials:MSPAS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:570-790-2391
Mailing Address - Fax:
Practice Address - Street 1:26 STATION CIR
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-9726
Practice Address - Country:US
Practice Address - Phone:570-501-6800
Practice Address - Fax:570-497-4046
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant