Provider Demographics
NPI:1629066436
Name:KEENE, NICHOLAS S (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:KEENE
Suffix:
Gender:M
Credentials:CRNA
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 17978
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-7978
Mailing Address - Country:US
Mailing Address - Phone:804-289-4937
Mailing Address - Fax:
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-289-4937
Practice Address - Fax:804-565-6600
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024104041367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629066436Medicaid
VA1629066436Medicaid