Provider Demographics
NPI:1558307066
Name:KEELEY, TANYA B (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:B
Last Name:KEELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:D,
Other - Last Name:BROUSSEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 55342
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33732-5342
Mailing Address - Country:US
Mailing Address - Phone:727-498-0629
Mailing Address - Fax:
Practice Address - Street 1:1200 7TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1300
Practice Address - Country:US
Practice Address - Phone:727-825-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY00S1OtherBLUE CROSS BLUE SHIELD
FL291815300Medicaid
FLY00S1OtherBLUE CROSS BLUE SHIELD
FL291815300Medicaid