Healthcare Provider Details

I. General information

NPI: 1134308067
Provider Name (Legal Business Name): SHANE A KECK MPA,PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2007
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CARILLON PT
KIRKLAND WA
98033-7306
US

IV. Provider business mailing address

3100 CARILLON POINT
KIRKLAND WA
98033-7306
US

V. Phone/Fax

Practice location:
  • Phone: 425-576-1700
  • Fax: 425-827-7725
Mailing address:
  • Phone: 425-576-1700
  • Fax: 425-827-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1187
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60021277
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: