Provider Demographics
NPI:1720032014
Name:GILBERT, KEITH A (PA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:GILBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811NEALSBURY BLVD 800
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2664
Mailing Address - Country:US
Mailing Address - Phone:817-293-7311
Mailing Address - Fax:
Practice Address - Street 1:1744 E ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4278
Practice Address - Country:US
Practice Address - Phone:423-636-8891
Practice Address - Fax:423-636-1732
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0100OtherUNITED HEALTHCARE RIVER V
P00291765OtherRAILROAD MEDICARE
P75327Medicare UPIN
TN3663651Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER