Provider Demographics
NPI:1841956778
Name:PERNELL, KEITH STEPHEN (PA)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:STEPHEN
Last Name:PERNELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42427 IBEX DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-2234
Mailing Address - Country:US
Mailing Address - Phone:808-375-7717
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:571-231-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA20001279363A00000X
VA0110007956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant