Provider Demographics
NPI:1356783906
Name:KOGA, KEITH KAZUTO (RN)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:KAZUTO
Last Name:KOGA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4300
Practice Address - Country:US
Practice Address - Phone:510-642-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719195163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse