Provider Demographics
NPI:1336692730
Name:KELLER, DESTINY C (PA-C)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:C
Last Name:KELLER
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 1:4304 CARLISLE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4811
Mailing Address - Country:US
Mailing Address - Phone:505-888-1075
Mailing Address - Fax:505-888-1082
Practice Address - Street 1:4304 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4811
Practice Address - Country:US
Practice Address - Phone:505-888-1075
Practice Address - Fax:505-888-1082
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0058363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical