Provider Demographics
NPI:1336653740
Name:KEENER, COLTON (PA)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:KEENER
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 1:1050 SE MONTEREY RD STE 302
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-210-2447
Mailing Address - Fax:
Practice Address - Street 1:1050 SE MONTEREY RD STE 302
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-210-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant