Provider Demographics
NPI:1619953270
Name:ALLEN, E KEITH (PAC)
Entity Type:Individual
Prefix:
First Name:E
Middle Name:KEITH
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6911 C AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1349
Mailing Address - Country:US
Mailing Address - Phone:319-832-1463
Mailing Address - Fax:319-832-1469
Practice Address - Street 1:6911 C AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-1349
Practice Address - Country:US
Practice Address - Phone:319-832-1463
Practice Address - Fax:319-832-1469
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45865Medicare ID - Type Unspecified
IAR59515Medicare UPIN