MEDICARE: KELSEY RANDALL PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		FL

General Provider Information

NPI Number	:	1184475592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY RANDALL PA

Provider Business Mailing Address
First Line	:	4401 N HIMES AVE STE 175
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-7095
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 N HIMES AVE STE 175
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-7095
Country	:	US
Telephone Number	:	813-393-3800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/01/2024

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Directions to “ KELSEY RANDALL PA” Practice Location

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