Provider Demographics
NPI:1013088954
Name:KEITH C DAMICO PA C PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:KEITH C DAMICO PA C PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:828-766-7278
Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:CROSSNORE
Mailing Address - State:NC
Mailing Address - Zip Code:28616-0448
Mailing Address - Country:US
Mailing Address - Phone:828-766-7278
Mailing Address - Fax:828-766-2849
Practice Address - Street 1:5235 NC 226 S
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8733
Practice Address - Country:US
Practice Address - Phone:828-652-3033
Practice Address - Fax:828-766-2849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102719363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty