Healthcare Provider Details

I. General information

NPI: 1972233641
Provider Name (Legal Business Name): KELSEY A LAGRUE MSPAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 STATION CIR
HAZLETON PA
18202-9726
US

IV. Provider business mailing address

2100 MACK BLVD
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6800
  • Fax: 570-497-4046
Mailing address:
  • Phone: 570-790-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063510
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: