Provider Demographics
NPI:1134308067
Name:KECK, SHANE A (MPA,PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:A
Last Name:KECK
Suffix:
Gender:M
Credentials:MPA,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CARILLON POINT
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7306
Mailing Address - Country:US
Mailing Address - Phone:425-576-1700
Mailing Address - Fax:425-827-7725
Practice Address - Street 1:3100 CARILLON PT
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7306
Practice Address - Country:US
Practice Address - Phone:425-576-1700
Practice Address - Fax:425-827-7725
Is Sole Proprietor?:No
Enumeration Date:2007-10-27
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1187363A00000X
WAPA60021277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200536260AMedicaid
KS200536260AMedicaid
KSJ64F743Medicare PIN
KS106978Medicare PIN