Provider Demographics
NPI:1790704963
Name:KEESE, LORETTA (PA)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:KEESE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 SOUTH HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5058
Mailing Address - Country:US
Mailing Address - Phone:830-997-2181
Mailing Address - Fax:830-997-9598
Practice Address - Street 1:1308 SOUTH HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-5058
Practice Address - Country:US
Practice Address - Phone:830-997-2181
Practice Address - Fax:830-997-9598
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210476201Medicaid
TX8L24420Medicare PIN