Provider Demographics
NPI:1952474041
Name:KEENE, LEROY NEAL (PAC)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:NEAL
Last Name:KEENE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-798-5147
Mailing Address - Fax:208-746-8741
Practice Address - Street 1:320 WARNER DRIVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-798-5147
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004927363A00000X
IDPA645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAC08OtherBCI
ID000010154322OtherREGENCE
WA8450645Medicaid
ID000010154322OtherREGENCE
WA8450645Medicaid
IDP0037498Medicare PIN
ID1667527Medicare PIN