Provider Demographics
NPI:1891260378
Name:WOLF, KEELY (PA-C)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:RIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2327 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1851
Mailing Address - Country:US
Mailing Address - Phone:541-889-2340
Mailing Address - Fax:
Practice Address - Street 1:2327 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1851
Practice Address - Country:US
Practice Address - Phone:541-889-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR190614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant