MEDICARE: STEPHEN C 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	PA-598	OK
2	363A00000X	Physician Assistant	PA2016-0078	NM

General Provider Information

NPI Number	:	1770596777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN C KELLER PA-C

Provider Business Mailing Address
First Line	:	4304 CARLISLE BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4811
Country	:	US
Telephone Number	:	505-888-1075
Fax Number	:	505-888-1082

Provider Business Practice Location Address
First Line	:	4304 CARLISLE BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4811
Country	:	US
Telephone Number	:	505-888-1075
Fax Number	:	505-888-1082

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	06/11/2018

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Directions to “ STEPHEN C KELLER PA-C” Practice Location

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