Provider Demographics
NPI:1154437317
Name:NOBACK, KEITH ALLAN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLAN
Last Name:NOBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:3830 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6920
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-286-0808
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6371A207Q00000X
AZ51526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115373100Medicaid
AZ111718Medicaid
WYH16528Medicare UPIN
WY308440Medicare ID - Type UnspecifiedMOORCROFT CLINIC
WY308438Medicare ID - Type UnspecifiedSUNDANCE CLINIC