Provider Demographics
NPI:1790061208
Name:KEENE, NELAE JONTUE (PA-C)
Entity Type:Individual
Prefix:
First Name:NELAE
Middle Name:JONTUE
Last Name:KEENE
Suffix:
Gender:F
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 1:2787 BRISTOL ST STE 210
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5956
Mailing Address - Country:US
Mailing Address - Phone:949-515-7300
Mailing Address - Fax:
Practice Address - Street 1:2787 BRISTOL ST STE 210
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5956
Practice Address - Country:US
Practice Address - Phone:949-515-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21875363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical