1396997110 NPI number — MRS. NICOLE C KEETER PA-C

Table of content: MRS. NICOLE C KEETER PA-C (NPI 1396997110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396997110 NPI number — MRS. NICOLE C KEETER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEETER
Provider First Name:
NICOLE
Provider Middle Name:
C
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396997110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 1ST BAXTER XING STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29708-8950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-802-3376
Provider Business Mailing Address Fax Number:
803-802-3329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 1ST BAXTER XING STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29708-8950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-802-3376
Provider Business Practice Location Address Fax Number:
803-802-3329
Provider Enumeration Date:
10/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0110003081 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA030560 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: TL3251 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)