Provider Demographics
NPI:1053176057
Name:SEDERQUEST, KELSEY JORDAN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JORDAN
Last Name:SEDERQUEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 ROCKY WAGON ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2615
Mailing Address - Country:US
Mailing Address - Phone:507-440-6102
Mailing Address - Fax:
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-572-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical