Provider Demographics
NPI:1972508968
Name:WANAMAKER, KEENAN C (DO)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:C
Last Name:WANAMAKER
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 1:7085 SYDNEY CURV
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3509
Mailing Address - Country:US
Mailing Address - Phone:334-246-4774
Mailing Address - Fax:334-246-2450
Practice Address - Street 1:7085 SYDNEY CURV
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3509
Practice Address - Country:US
Practice Address - Phone:334-246-4774
Practice Address - Fax:334-246-2450
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3721208600000X, 2086S0129X
ALDO-900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG12825Medicare UPIN