Healthcare Provider Details

I. General information

NPI: 1710762588
Provider Name (Legal Business Name): RYAN KEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E LAKEVIEW AVE
WOODLAKE CA
93286-1301
US

IV. Provider business mailing address

1462 CLIFTON RD NE STE 280
ATLANTA GA
30322-1063
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 404-727-7825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: