Provider Demographics
NPI:1275816167
Name:KEATING, KRISTIN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:KEATING
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:2233 W DIVISION ST
Mailing Address - Street 2:MEDICAL STAFF ADMINISTRATION AND CREDENTIALING
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8151
Mailing Address - Country:US
Mailing Address - Phone:312-770-2062
Mailing Address - Fax:312-770-3264
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:MEDICAL STAFF ADMINISTRATION AND CREDENTIALING
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8151
Practice Address - Country:US
Practice Address - Phone:312-770-2062
Practice Address - Fax:312-770-3264
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-11-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA055067363A00000X
IL085.004238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant