Provider Demographics
NPI:1902144983
Name:PETERSON, KELSEY ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELSEY
Other - Middle Name:ROSE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:520 MEDICAL CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4316
Mailing Address - Country:US
Mailing Address - Phone:541-930-8907
Mailing Address - Fax:541-245-4820
Practice Address - Street 1:1245 NW 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-598-3485
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA164169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500670083Medicaid