Provider Demographics
NPI:1497138861
Name:KELLER, MARK ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 15TH PL SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-3830
Mailing Address - Country:US
Mailing Address - Phone:610-392-7647
Mailing Address - Fax:
Practice Address - Street 1:7205 265TH ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6221
Practice Address - Country:US
Practice Address - Phone:360-629-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-03
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209962208000000X
WAMD61049864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics