Healthcare Provider Details

I. General information

NPI: 1215811948
Provider Name (Legal Business Name): GEORGE KEITHAN III APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 FARMINGTON AVE STE 202
FARMINGTON CT
06032-2383
US

IV. Provider business mailing address

204 HIDDEN LAKE RD
HIGGANUM CT
06441-4502
US

V. Phone/Fax

Practice location:
  • Phone: 860-837-5170
  • Fax:
Mailing address:
  • Phone: 860-510-1157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18019
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10.188585
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: