Provider Demographics
NPI:1790719839
Name:KEO, SOTA (ANP-C)
Entity Type:Individual
Prefix:MS
First Name:SOTA
Middle Name:
Last Name:KEO
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15147 W CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5236
Mailing Address - Country:US
Mailing Address - Phone:623-217-3318
Mailing Address - Fax:
Practice Address - Street 1:10147 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3435
Practice Address - Country:US
Practice Address - Phone:602-222-2631
Practice Address - Fax:602-222-2633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1891363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health