Provider Demographics
NPI:1114095064
Name:KELLER, JULIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:KELLER
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 1:922 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:ND
Mailing Address - Zip Code:58341-1524
Mailing Address - Country:US
Mailing Address - Phone:701-324-4856
Mailing Address - Fax:701-324-4858
Practice Address - Street 1:922 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:ND
Practice Address - Zip Code:58341-1524
Practice Address - Country:US
Practice Address - Phone:701-324-4856
Practice Address - Fax:701-324-4858
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12048OtherBLUE CROSS BLUE SHIELD
ND10310Medicaid
R02362Medicare UPIN
12048OtherBLUE CROSS BLUE SHIELD