Provider Demographics
NPI:1407855364
Name:KELTNER, RICHARD S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:S
Last Name:KELTNER
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000536A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000659907OtherANTHEM BC/BS
IN970021354OtherRAILROAD MEDICARE
IN000000626065OtherANTHEM BC/BS
INP00775296OtherRAILROAD MEDICARE
IN000000340099OtherBLUE CROSS/BLUE SHIELD
INP00841047OtherRAILROAD MEDICARE
INP47436Medicare UPIN
IN970021354OtherRAILROAD MEDICARE
INP01307367Medicare PIN
IN265520VMedicare PIN
IN261920UMedicare PIN