Provider Demographics
NPI:1336126259
Name:KECKLEY, W. DALE (PA)
Entity Type:Individual
Prefix:
First Name:W. DALE
Middle Name:
Last Name:KECKLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:GENERAL SURGERY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-6227
Practice Address - Country:US
Practice Address - Phone:860-679-8080
Practice Address - Fax:860-679-1420
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001065363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1336126259Medicaid
CT1336126259Medicaid