Provider Demographics
NPI:1992436513
Name:AUSTIN, KELSEY (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8237 TUNA PATH
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1347
Mailing Address - Country:US
Mailing Address - Phone:315-200-7070
Mailing Address - Fax:
Practice Address - Street 1:1120 FIRST COLONIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-481-2333
Practice Address - Fax:844-245-8666
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110009575363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program