Provider Demographics
NPI:1912026790
Name:KEENPORTZ, BRENT WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WAYNE
Last Name:KEENPORTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16405 WEIR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1218
Mailing Address - Country:US
Mailing Address - Phone:402-699-1991
Mailing Address - Fax:
Practice Address - Street 1:2620 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4205
Practice Address - Country:US
Practice Address - Phone:308-398-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19924207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology