Provider Demographics
NPI:1043356645
Name:ADAMS, KETA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KETA
Middle Name:A
Last Name:ADAMS
Suffix:
Gender:F
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 1:5304 BLOOMSBURY WAY
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-6069
Mailing Address - Country:US
Mailing Address - Phone:979-774-2216
Mailing Address - Fax:
Practice Address - Street 1:305 W GAY ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TX
Practice Address - Zip Code:77856-4871
Practice Address - Country:US
Practice Address - Phone:979-828-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03071363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR29287Medicare UPIN