Provider Demographics
NPI:1821295668
Name:MCKEITHAN, EDWARD MARVIN (NP)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARVIN
Last Name:MCKEITHAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N FRONT ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4055
Mailing Address - Country:US
Mailing Address - Phone:910-500-6451
Mailing Address - Fax:910-500-6458
Practice Address - Street 1:201 N FRONT ST STE 102
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4055
Practice Address - Country:US
Practice Address - Phone:910-500-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC105024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992351910OtherBCBS