Provider Demographics
NPI:1154763050
Name:KELLER, MICHELLE RENAE-PIPPEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE-PIPPEL
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENAE-PIPPEL
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 NW SAMARITAN DR
Practice Address - Street 2:SUITE 210
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3783
Practice Address - Country:US
Practice Address - Phone:541-768-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
ORPA173678363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILF400173350OtherMEDICARE PTAN (INDIVIDUAL)