Provider Demographics
NPI:1285203901
Name:MEINECKE, KEITH ORVAL (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ORVAL
Last Name:MEINECKE
Suffix:
Gender:M
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 1:498 THORN TREE DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-8003
Mailing Address - Country:US
Mailing Address - Phone:704-451-3711
Mailing Address - Fax:
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-268-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant