Provider Demographics
NPI:1295884690
Name:KELLER, PATRICIA A (ANP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-0192
Mailing Address - Country:US
Mailing Address - Phone:516-629-2468
Mailing Address - Fax:631-465-6524
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-414-3235
Practice Address - Fax:516-562-6671
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303588363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02362581Medicaid
NY0808G1Medicare ID - Type Unspecified
NY02362581Medicaid