Healthcare Provider Details

I. General information

NPI: 1629169396
Provider Name (Legal Business Name): KEITH WILLIAM MCGILL PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S PICO AVE 14342 BORA DR LA MIRADA 90638
LONG BEACH CA
90802
US

IV. Provider business mailing address

150 S PICO AVE 14342 BORA DRIVE LA MIRADA, CA 90638
LONG BEACH CA
90802-6247
US

V. Phone/Fax

Practice location:
  • Phone: 562-432-2821
  • Fax: 562-437-1353
Mailing address:
  • Phone: 562-432-2821
  • Fax: 562-437-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 11313
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA11313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: