Provider Demographics
NPI:1942402169
Name:KELLER, WADE ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:ROBERT
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E RVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-939-6227
Mailing Address - Fax:208-939-6442
Practice Address - Street 1:1605 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6237
Practice Address - Country:US
Practice Address - Phone:208-939-6227
Practice Address - Fax:208-939-6442
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4692207N00000X
IDO-0559207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology