Provider Demographics
NPI:1134278419
Name:KELLER, PATRICIA P (CSA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:P
Last Name:KELLER
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-0009
Mailing Address - Country:US
Mailing Address - Phone:770-940-0185
Mailing Address - Fax:949-437-3333
Practice Address - Street 1:6144 STELLA LIGHT DR
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3451
Practice Address - Country:US
Practice Address - Phone:770-940-0185
Practice Address - Fax:949-437-3333
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA92821246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA92821OtherNBSTSA CERTIFICATION CST/CSFA