Basic Information
Provider Information | |||||||||
NPI: | 1467051821 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUCHMORE | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEISS | ||||||||
OtherFirstName: | KELSEY | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4685 FOREST AVE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452123397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132461964 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10600 MONTGOMERY RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | OH | ||||||||
PostalCode: | 452424464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138539250 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2020 | ||||||||
LastUpdateDate: | 12/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.006594RX | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0459280 | 05 | OH |   | MEDICAID |