Healthcare Provider Details

I. General information

NPI: 1871871525
Provider Name (Legal Business Name): MARK DAVID KEESLING FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3647 J DEWEY GRAY CIR STE 200
AUGUSTA GA
30909-2205
US

IV. Provider business mailing address

811 13TH ST STE 20
AUGUSTA GA
30901-2771
US

V. Phone/Fax

Practice location:
  • Phone: 706-504-9712
  • Fax: 706-504-9703
Mailing address:
  • Phone: 706-722-3401
  • Fax: 706-724-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN193399
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.17582RX
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN193399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: