Provider Demographics
NPI:1760792857
Name:DESONIER, KEITH F JR (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:F
Last Name:DESONIER
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 12TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-871-9069
Mailing Address - Fax:817-871-9067
Practice Address - Street 1:1001 12TH AVE STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-871-9069
Practice Address - Fax:817-871-9067
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218752802Medicaid
TX218752803Medicaid
TX218752801Medicaid
TXTXB117747Medicare PIN
TX218752802Medicaid
TX218752803Medicaid