Provider Demographics
NPI:1588665186
Name:KELLER, RICHARD ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:KELLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5807
Mailing Address - Country:US
Mailing Address - Phone:817-599-1200
Mailing Address - Fax:817-341-7351
Practice Address - Street 1:891 EUREKA ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5807
Practice Address - Country:US
Practice Address - Phone:817-599-1200
Practice Address - Fax:817-341-7351
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7198739OtherAETNA PROVIDER #
TX85N676Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
TXP23771Medicare UPIN