Provider Demographics
NPI:1801131057
Name:DEARDORFF, KEITH ALAN
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALAN
Last Name:DEARDORFF
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 1:4763 POLEPLANT DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5255
Mailing Address - Country:US
Mailing Address - Phone:850-305-4495
Mailing Address - Fax:
Practice Address - Street 1:4763 POLEPLANT DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5255
Practice Address - Country:US
Practice Address - Phone:850-305-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996683-NP363LF0000X
OHCOA.14807.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily