Healthcare Provider Details

I. General information

NPI: 1366951253
Provider Name (Legal Business Name): KELSEY MARIE GLIDEWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2017
Last Update Date: 12/08/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

PHR GROUP PROVIDER ENROLLMENT UNIT 393 E WALNUT ST FL 3
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-6170
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number54919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: