Provider Demographics
NPI:1205729928
Name:KEITA, MODIBO
Entity type:Individual
Prefix:MR
First Name:MODIBO
Middle Name:
Last Name:KEITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8908 PREAKNESS CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-3582
Mailing Address - Country:US
Mailing Address - Phone:352-870-7404
Mailing Address - Fax:
Practice Address - Street 1:8908 PREAKNESS CIR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-3582
Practice Address - Country:US
Practice Address - Phone:352-870-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX885241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered