Provider Demographics
NPI:1265603195
Name:KEIL, JEFFREY J (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:KEIL
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 1:20940 N TATUM BLVD
Mailing Address - Street 2:STE B 290
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050
Mailing Address - Country:US
Mailing Address - Phone:602-734-1834
Mailing Address - Fax:602-734-1835
Practice Address - Street 1:20940 N TATUM BLVD
Practice Address - Street 2:STE B 290
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050
Practice Address - Country:US
Practice Address - Phone:602-734-1834
Practice Address - Fax:602-734-1835
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3821363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ402301Medicaid
3Z3912OtherHEALTHNET ID
AZZ136771Medicare PIN
AZ402301Medicaid