Provider Demographics
NPI:1639670060
Name:DEPASQUALE, KEIKO MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEIKO
Middle Name:MARIE
Last Name:DEPASQUALE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KEIKO
Other - Middle Name:
Other - Last Name:WADSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2615 LAKE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2615 LAKE DR STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6694
Practice Address - Country:US
Practice Address - Phone:919-781-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-03424207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology