Provider Demographics
NPI:1336190172
Name:KEENE, KRISTOPHER A (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:A
Last Name:KEENE
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 1:67780 E PALM CANYON DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67780 E PALM CANYON DR
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-5441
Practice Address - Country:US
Practice Address - Phone:760-770-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
007906261NOtherHUMANA
CA51625OtherPHYSICIAN ASSISTANT
Q03012Medicare UPIN
WI680860639Medicare PIN
007906261NOtherHUMANA