Provider Demographics
NPI:1780060319
Name:VAUGHAN, KEELY E (PA-C)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:E
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3309
Mailing Address - Country:US
Mailing Address - Phone:731-587-9511
Mailing Address - Fax:877-309-6416
Practice Address - Street 1:117 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3394
Practice Address - Country:US
Practice Address - Phone:731-587-9511
Practice Address - Fax:877-309-6416
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA2812363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018026Medicaid
5440149OtherBCBS
2153951OtherCIGNA
3815442OtherAMERIGROUP
P01577761OtherRAIL ROAD MEDICARE