Healthcare Provider Details

I. General information

NPI: 1336653740
Provider Name (Legal Business Name): COLTON KEENER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SE MONTEREY RD STE 302
STUART FL
34994-4512
US

IV. Provider business mailing address

1050 SE MONTEREY RD STE 302
STUART FL
34994-4512
US

V. Phone/Fax

Practice location:
  • Phone: 772-210-2447
  • Fax:
Mailing address:
  • Phone: 772-210-2447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067397
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110838
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: