Provider Demographics
NPI:1144228925
Name:FERRIS, KEITH M (PA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:FERRIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2428 HEATHERGLEN DR
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1028
Mailing Address - Country:US
Mailing Address - Phone:419-868-1349
Mailing Address - Fax:
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-5318
Practice Address - Fax:419-291-6430
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50001382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070822Medicaid
OH98669Medicare UPIN
OH75651Medicare PIN
OH970012824Medicare PIN