Provider Demographics
NPI:1649374331
Name:KEELEY, JOHN R (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KEELEY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-681-3146
Mailing Address - Fax:914-457-1198
Practice Address - Street 1:210 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2901
Practice Address - Country:US
Practice Address - Phone:914-682-6540
Practice Address - Fax:914-682-6541
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003134363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P 15733Medicare UPIN
0F8471Medicare ID - Type Unspecified