Provider Demographics
NPI:1912190950
Name:PROCTOR, KEIRA ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KEIRA
Middle Name:ROSE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEIRA
Other - Middle Name:ROSE
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:248 PLEASANT ST STE 2800
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7529
Mailing Address - Country:US
Mailing Address - Phone:603-224-5200
Mailing Address - Fax:603-227-7559
Practice Address - Street 1:248 PLEASANT ST STE 2800
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7529
Practice Address - Country:US
Practice Address - Phone:603-224-5200
Practice Address - Fax:603-227-7559
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2353363A00000X, 363AS0400X
NH1398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0002193OtherMEDICARE PTAN