Provider Demographics
NPI:1922021401
Name:WELCH, KEIVER T (PA)
Entity Type:Individual
Prefix:
First Name:KEIVER
Middle Name:T
Last Name:WELCH
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8941
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3900
Practice Address - Country:US
Practice Address - Phone:207-907-3650
Practice Address - Fax:207-907-3660
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MEPA-170363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2844600999Medicaid
ME2844600999Medicaid