Healthcare Provider Details

I. General information

NPI: 1306829676
Provider Name (Legal Business Name): MICHAEL PAUL KELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE STE 202
LAS CRUCES NM
88011-8260
US

IV. Provider business mailing address

4351 E LOHMAN AVE STE 202
LAS CRUCES NM
88011-8260
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5955
  • Fax: 575-522-6228
Mailing address:
  • Phone: 575-522-5955
  • Fax: 575-522-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001231
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2001231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: