Provider Demographics
NPI:1700285111
Name:KEANE, BROGAN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:BROGAN
Middle Name:NICOLE
Last Name:KEANE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROGAN
Other - Middle Name:
Other - Last Name:GUEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4515 LIBERTY AVENUE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-1152
Mailing Address - Fax:412-330-5522
Practice Address - Street 1:4815 LIBERTY AVE
Practice Address - Street 2:SUITE 222
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:724-747-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant