Provider Demographics
NPI:1588631469
Name:KECK, ANNE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:M
Last Name:KECK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:VANDERBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-6013
Mailing Address - Country:US
Mailing Address - Phone:860-718-5242
Mailing Address - Fax:
Practice Address - Street 1:5 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-6013
Practice Address - Country:US
Practice Address - Phone:860-718-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001876363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002503Medicare UPIN
Q63882Medicare UPIN
CTQ63882Medicare UPIN
Q63882Medicare UPIN