Provider Demographics
NPI:1659346740
Name:MACKSOUD, KEITH E (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:MACKSOUD
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 1:1817 OLD LOUISQUISSET PIKE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4516
Mailing Address - Country:US
Mailing Address - Phone:401-727-2443
Mailing Address - Fax:401-729-3476
Practice Address - Street 1:1817 OLD LOUISQUISSET PIKE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4516
Practice Address - Country:US
Practice Address - Phone:401-727-2443
Practice Address - Fax:401-729-3476
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRNA24719367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered