Healthcare Provider Details

I. General information

NPI: 1912692013
Provider Name (Legal Business Name): KEEGAN FERNANDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12997 WARWICK BLVD
NEWPORT NEWS VA
23602-8352
US

IV. Provider business mailing address

129 N WASHINGTON ST
SUMTER SC
29150-4949
US

V. Phone/Fax

Practice location:
  • Phone: 757-369-9446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102210000
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL89933
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: