Provider Demographics
NPI:1164168241
Name:KELLER, GREGORY ALEXANDER (ATC, NREMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALEXANDER
Last Name:KELLER
Suffix:
Gender:M
Credentials:ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 DISCOVERY BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6964
Mailing Address - Country:US
Mailing Address - Phone:317-658-8028
Mailing Address - Fax:
Practice Address - Street 1:1608 DISCOVERY BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6964
Practice Address - Country:US
Practice Address - Phone:317-658-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT65692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer