Basic Information
| Provider Information | |||||||||
| NPI: | 1609345214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICE | ||||||||
| FirstName: | KELSEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
| FaxNumber: | 8177028445 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N LAMAR ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761960216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172486209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2018 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA12092 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA12092 | 01 | TX | TEXAS PHYSICIAN ASSISTANT BOARD | OTHER | 1151968 | 01 | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS | OTHER |