Provider Demographics
NPI:1205689783
Name:KEO, TARAROTH PEN
Entity type:Individual
Prefix:
First Name:TARAROTH
Middle Name:PEN
Last Name:KEO
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 1:1134 BRIANNA AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-2931
Mailing Address - Country:US
Mailing Address - Phone:661-902-3369
Mailing Address - Fax:
Practice Address - Street 1:43932 15TH ST W STE 103
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-5234
Practice Address - Country:US
Practice Address - Phone:661-945-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily