Provider Demographics
NPI:1134852593
Name:KEOUGH, PAIGE NICOLE
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:NICOLE
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9792 OAKLAWN BLVD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-0176
Mailing Address - Country:US
Mailing Address - Phone:717-968-7158
Mailing Address - Fax:
Practice Address - Street 1:1085 NE GATEWAY CT NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2406
Practice Address - Country:US
Practice Address - Phone:704-707-2203
Practice Address - Fax:704-707-2203
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12635208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology