Provider Demographics
NPI:1437193927
Name:MUNOZ, KEITH W SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:W
Last Name:MUNOZ
Suffix:SR
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:PO BOX 1276
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1276
Mailing Address - Country:US
Mailing Address - Phone:229-236-0831
Mailing Address - Fax:229-236-0871
Practice Address - Street 1:100 S MADISON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5473
Practice Address - Country:US
Practice Address - Phone:229-236-0831
Practice Address - Fax:229-236-0871
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA299512679CMedicaid
GAP001145189OtherRAILROAD
GA083704148OtherTRICARE
GAP001145189OtherRAILROAD
GAQ23175Medicare UPIN