Healthcare Provider Details

I. General information

NPI: 1679571475
Provider Name (Legal Business Name): BART R KELLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S WILCOX ST
CASTLE ROCK CO
80104-2662
US

IV. Provider business mailing address

410 S WILCOX ST
CASTLE ROCK CO
80104-2662
US

V. Phone/Fax

Practice location:
  • Phone: 303-688-6900
  • Fax: 303-660-6504
Mailing address:
  • Phone: 303-688-6900
  • Fax: 303-660-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003377
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601002360
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: