Provider Demographics
NPI:1902820780
Name:KELLER, TONA J (PA-C)
Entity Type:Individual
Prefix:
First Name:TONA
Middle Name:J
Last Name:KELLER
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:PO BOX 1263
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-1263
Mailing Address - Country:US
Mailing Address - Phone:409-933-0733
Mailing Address - Fax:409-933-9777
Practice Address - Street 1:6510 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-4016
Practice Address - Country:US
Practice Address - Phone:409-933-0733
Practice Address - Fax:409-933-9777
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0053KDOtherBLUE CROSS BLUE SHIELD
TXDA0825OtherMEDICARE RAILROAD
00572KMedicare ID - Type Unspecified
TXDA0825OtherMEDICARE RAILROAD
TX8D1912Medicare PIN