Healthcare Provider Details

I. General information

NPI: 1720563000
Provider Name (Legal Business Name): KELSEY HAAG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 07/22/2023
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 JEFFERSON RD STE 100
ROCHESTER NY
14623-3195
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-413-1800
  • Fax:
Mailing address:
  • Phone: 585-273-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number22747
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: