MEDICARE: KELSEY MASTER PA-C

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	363AS0400X	Surgical Physician Assistant	PA12885	TX
2	363AM0700X	Medical Physician Assistant	PA12885	TX

General Provider Information

NPI Number	:	1821641051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY MASTER PA-C

Provider Business Mailing Address
First Line	:	1309 MAIN ST APT 1805
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75202-4104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12201 MERIT DR STE 400
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75251-3117
Country	:	US
Telephone Number	:	469-840-4888
Fax Number	:

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

Provider Enumeration Date	:	07/17/2019
Last Update Date	:	09/01/2021

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Directions to “ KELSEY MASTER PA-C” Practice Location

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