Provider Demographics
NPI:1275509408
Name:KEITH, SHARONDA EVETTE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHARONDA
Middle Name:EVETTE
Last Name:KEITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY STREET, APC-6
Mailing Address - Street 2:LIFESPAN PHYSICIAN'S GROUP, DEPT OF NEUROSURGERY
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-793-9138
Mailing Address - Fax:401-444-2781
Practice Address - Street 1:593 EDDY STREET, APC-6
Practice Address - Street 2:LIFESPAN PHYSICIAN'S GROUP, DEPT OF NEUROSURGERY
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-793-9138
Practice Address - Fax:401-444-2781
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003694363A00000X
RIPA00823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400250783Medicare UPIN