Basic Information
| Provider Information | |||||||||
| NPI: | 1750777249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAMOND | ||||||||
| FirstName: | KELSEY | ||||||||
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| OtherLastName: | DIAMOND | ||||||||
| OtherFirstName: | KELSEY | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173891 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193655000 | ||||||||
| FaxNumber: | 7193656827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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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 | 10001788A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.0005282 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.