Provider Demographics
NPI:1063496602
Name:KELLER, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1755
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-5891
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR080041637OtherRR MEDICARE PTAN NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR043831Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR930635514OtherGROUP TAX ID NUMBER
OR043831Medicaid