Provider Demographics
NPI:1467203448
Name:WEATHERS, KEITH ALAN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 KINGS CT
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5003
Mailing Address - Country:US
Mailing Address - Phone:707-391-6296
Mailing Address - Fax:
Practice Address - Street 1:630 KINGS CT
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5003
Practice Address - Country:US
Practice Address - Phone:707-468-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist