Provider Demographics
NPI:1740594928
Name:KELLER, ANDREA LYNN (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 WOODBURN RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1229
Mailing Address - Country:US
Mailing Address - Phone:703-698-9254
Mailing Address - Fax:703-698-9256
Practice Address - Street 1:3301 WOODBURN RD
Practice Address - Street 2:SUITE 209
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1229
Practice Address - Country:US
Practice Address - Phone:703-698-9254
Practice Address - Fax:703-698-9256
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA13101003000527OtherCMS/MEDICATE PECOS