Provider Demographics
NPI:1497498430
Name:SAMMONS, KEEGAN WADE
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:WADE
Last Name:SAMMONS
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 1:171 GAZETTE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-3271
Mailing Address - Country:US
Mailing Address - Phone:606-356-8587
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS, INC.
Practice Address - Street 2:8701 WATERTOWN PLANK RD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-955-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program