MEDICARE: NELAE JONTUE KEENE 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	363AM0700X	Medical Physician Assistant	21875	CA

General Provider Information

NPI Number	:	1790061208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELAE JONTUE KEENE PA-C

Provider Business Mailing Address
First Line	:	2787 BRISTOL ST STE 210
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5956
Country	:	US
Telephone Number	:	949-515-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2787 BRISTOL ST STE 210
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5956
Country	:	US
Telephone Number	:	949-515-7300
Fax Number	:

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

Provider Enumeration Date	:	10/28/2011
Last Update Date	:	12/12/2018

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