Healthcare Provider Details

I. General information

NPI: 1376289033
Provider Name (Legal Business Name): KELSIE ELIZABETH LUSK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2421
US

IV. Provider business mailing address

829 IDLEWOOD ST
MORGANTOWN WV
26505-8333
US

V. Phone/Fax

Practice location:
  • Phone: 304-285-7222
  • Fax:
Mailing address:
  • Phone: 304-685-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2644
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberTEMP2965
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: