Provider Demographics
NPI:1124008404
Name:KELLER, PATRICK (PTA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 FROWEIN RD
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-2006
Mailing Address - Country:US
Mailing Address - Phone:631-467-4235
Mailing Address - Fax:631-467-2655
Practice Address - Street 1:141 MARK TREE RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2221
Practice Address - Country:US
Practice Address - Phone:631-467-4235
Practice Address - Fax:631-467-2655
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006346-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant