Provider Demographics
NPI:1598779399
Name:KELLER, ROBERT MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
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:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-2000
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:910-295-0244
Practice Address - Street 1:5 FIRST VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8724
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:910-295-0244
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103335363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12586OtherBCBS NC
NC8912586Medicaid
P00102532OtherRAILROAD MEDICARE
P48966Medicare UPIN
2753832AMedicare ID - Type Unspecified