Provider Demographics
NPI:1720052640
Name:KELLER, CHAD J (MSED, BSN, RN, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:J
Last Name:KELLER
Suffix:
Gender:M
Credentials:MSED, BSN, RN, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 S MICHELLE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-6690
Mailing Address - Country:US
Mailing Address - Phone:913-850-8388
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-003152255A2300X
KS13-116483-012163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS24-00315OtherKANSAS STATE BOARD OF HEALING ARTS (ATHLETIC TRAINER) AT
KS13-116483-012OtherKANSAS STATE BOARD OF NURSING (REGISTERED NURSE)