Provider Demographics
NPI:1619037249
Name:POWELL, KEITH ALLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALLEN
Last Name:POWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3 GARVIN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 RAYMOND ST
Practice Address - Street 2:CANTON POTSDAM HOSPITAL
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1163
Practice Address - Country:US
Practice Address - Phone:315-261-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant