Provider Demographics
NPI:1740956820
Name:BOGGS, WILLIAM KEITH (PTA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEITH
Last Name:BOGGS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522-9032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:945 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522-9032
Practice Address - Country:US
Practice Address - Phone:606-754-4134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant