Provider Demographics
NPI:1154583094
Name:KEATING, KATHLEEN C (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
Last Name:KEATING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:970-826-2429
Practice Address - Street 1:100 E IDAHO ST STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-345-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45921207V00000X
COTL45921390200000X
IDO-0685207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13131834Medicaid