Provider Demographics
NPI:1588042345
Name:PICKENS, KESHIA (PA)
Entity Type:Individual
Prefix:
First Name:KESHIA
Middle Name:
Last Name:PICKENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3440 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE 460
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6927
Mailing Address - Country:US
Mailing Address - Phone:954-923-7440
Mailing Address - Fax:954-923-1299
Practice Address - Street 1:6850 N DURANGO DR
Practice Address - Street 2:SUITE 204
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4595
Practice Address - Country:US
Practice Address - Phone:954-923-7440
Practice Address - Fax:954-923-1299
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA1626OtherMEDICAL LICENSE