Provider Demographics
NPI:1124192406
Name:KELLER, DAVID V (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:V
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 1:1424 FERN CREEK DR STE D
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9376
Mailing Address - Country:US
Mailing Address - Phone:704-878-2058
Mailing Address - Fax:704-872-6576
Practice Address - Street 1:1424 FERN CREEK DR STE D
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9376
Practice Address - Country:US
Practice Address - Phone:704-878-2058
Practice Address - Fax:704-872-6576
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00703363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2768030AMedicare PIN
Q76721Medicare UPIN