Provider Demographics
NPI:1235402447
Name:WOMMACK, KEITH AUSTIN (CSB)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:AUSTIN
Last Name:WOMMACK
Suffix:
Gender:M
Credentials:CSB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 RONSON DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-3152
Mailing Address - Country:US
Mailing Address - Phone:361-992-2487
Mailing Address - Fax:361-991-6310
Practice Address - Street 1:514 RONSON DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-3152
Practice Address - Country:US
Practice Address - Phone:361-992-2487
Practice Address - Fax:361-991-6310
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner