Provider Demographics
NPI:1538448535
Name:DEVINE, KELSEY E (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:E
Last Name:DEVINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:E
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1823 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502
Mailing Address - Country:US
Mailing Address - Phone:785-776-3322
Mailing Address - Fax:
Practice Address - Street 1:1823 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3381
Practice Address - Country:US
Practice Address - Phone:785-776-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01475363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200738910CMedicaid
KS068002134OtherMEDICARE PTRAN