Provider Demographics
NPI:1295080588
Name:PULLIN, KEITH LAUREN (PT, DPT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:LAUREN
Last Name:PULLIN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WIKIUP DR STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1375
Mailing Address - Country:US
Mailing Address - Phone:707-542-5400
Mailing Address - Fax:
Practice Address - Street 1:101 WIKIUP DR STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1375
Practice Address - Country:US
Practice Address - Phone:707-542-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist