Healthcare Provider Details

I. General information

NPI: 1831890292
Provider Name (Legal Business Name): LAURA KEANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 E CLAY ST
RICHMOND VA
23298-5071
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 800-762-6161
  • Fax:
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009229
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: