MEDICARE: RICHARD ALLEN KELLER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00270	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7198739	OTHER	TX	AETNA PROVIDER #

General Provider Information

NPI Number	:	1588665186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD ALLEN KELLER PA-C

Provider Business Mailing Address
First Line	:	891 EUREKA ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5807
Country	:	US
Telephone Number	:	817-599-1200
Fax Number	:	817-341-7351

Provider Business Practice Location Address
First Line	:	891 EUREKA ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5807
Country	:	US
Telephone Number	:	817-599-1200
Fax Number	:	817-341-7351

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	08/26/2020

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