Provider Demographics
NPI:1417965526
Name:KILLEN, BRIAN KEITH (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:KILLEN
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 1:1 MEDICAL PARK BLVD STE 400E
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7431
Mailing Address - Country:US
Mailing Address - Phone:423-844-5400
Mailing Address - Fax:423-844-5434
Practice Address - Street 1:1 MEDICAL PARK BLVD STE 400E
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7431
Practice Address - Country:US
Practice Address - Phone:423-844-5400
Practice Address - Fax:423-844-5434
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1085363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512862Medicaid
366003Medicare ID - Type Unspecified
TN1512862Medicaid