Provider Demographics
NPI:1770365660
Name:KEATON, GAGE
Entity type:Individual
Prefix:
First Name:GAGE
Middle Name:
Last Name:KEATON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MONTICELLO BLVD APT 104
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1764
Mailing Address - Country:US
Mailing Address - Phone:567-224-8211
Mailing Address - Fax:
Practice Address - Street 1:4000 MONTICELLO BLVD APT 104
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1764
Practice Address - Country:US
Practice Address - Phone:567-224-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.463925163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse