Provider Demographics
NPI:1033259296
Name:KELLER, WILLIAM B (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:KELLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14400 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2703
Mailing Address - Country:US
Mailing Address - Phone:941-423-5056
Mailing Address - Fax:941-423-5068
Practice Address - Street 1:14400 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2703
Practice Address - Country:US
Practice Address - Phone:941-423-5056
Practice Address - Fax:941-423-5068
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12605910OtherCAQH
FL54084OtherBC/BS
FLPA 3132OtherPA LICENSE