1063487015 NPI number — MR. ALAN M. KEATING PA-C

Table of content: MR. ALAN M. KEATING PA-C (NPI 1063487015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063487015 NPI number — MR. ALAN M. KEATING PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEATING
Provider First Name:
ALAN
Provider Middle Name:
M.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1063487015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1765 OLD WEST BROAD ST BLDG 2-200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-549-1663
Provider Business Mailing Address Fax Number:
706-549-1663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1553 JANMAR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNELLVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30078-5606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-554-5009
Provider Business Practice Location Address Fax Number:
706-546-8792
Provider Enumeration Date:
02/22/2006

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:  2995 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11945081 . This is a "CAQH #" identifier . This identifiers is of the category "OTHER".




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