Healthcare Provider Details

I. General information

NPI: 1770365660
Provider Name (Legal Business Name): GAGE KEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MONTICELLO BLVD APT 104
YOUNGSTOWN OH
44505-1764
US

IV. Provider business mailing address

4000 MONTICELLO BLVD APT 104
YOUNGSTOWN OH
44505-1764
US

V. Phone/Fax

Practice location:
  • Phone: 567-224-8211
  • Fax:
Mailing address:
  • Phone: 567-224-8211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0021309
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.463925
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: