Provider Demographics
NPI:1972901650
Name:MCINNERNEY, KEITH VINCENT (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:VINCENT
Last Name:MCINNERNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N KIMBALL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6886
Mailing Address - Country:US
Mailing Address - Phone:817-421-8777
Mailing Address - Fax:817-421-4388
Practice Address - Street 1:630 N KIMBALL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6886
Practice Address - Country:US
Practice Address - Phone:817-421-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2585363AM0700X
TXPA09502363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical