Provider Demographics
NPI:1629169396
Name:MCGILL, KEITH WILLIAM (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WILLIAM
Last Name:MCGILL
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:150 S PICO AVE
Mailing Address - Street 2:14342 BORA DRIVE LA MIRADA, CA 90638
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-6247
Mailing Address - Country:US
Mailing Address - Phone:562-432-2821
Mailing Address - Fax:562-437-1353
Practice Address - Street 1:150 S PICO AVE
Practice Address - Street 2:14342 BORA DR LA MIRADA 90638
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:562-432-2821
Practice Address - Fax:562-437-1353
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11313207N00000X
CAPA 11313363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11313OtherPHYSICIAN ASST. LICENSE #