Healthcare Provider Details

I. General information

NPI: 1790704963
Provider Name (Legal Business Name): LORETTA KEESE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 SOUTH HIGHWAY 16
FREDERICKSBURG TX
78624-5058
US

IV. Provider business mailing address

1308 SOUTH HIGHWAY 16
FREDERICKSBURG TX
78624-5058
US

V. Phone/Fax

Practice location:
  • Phone: 830-997-2181
  • Fax: 830-997-9598
Mailing address:
  • Phone: 830-997-2181
  • Fax: 830-997-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04251
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: