Healthcare Provider Details

I. General information

NPI: 1538614763
Provider Name (Legal Business Name): KELSEY MCMAHON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 S 17TH ST STE 310
LINCOLN NE
68502-3700
US

IV. Provider business mailing address

2207 OSBORNE DR W SUITE 100
HASTINGS NE
68901-9112
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-8555
  • Fax: 402-483-8554
Mailing address:
  • Phone: 402-462-2139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2053
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: