Provider Demographics
NPI:1194506477
Name:KEATE, JUSTIN THOMAS (RN)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:KEATE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 S 300 W
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10196201-3102163W00000X
ID78567367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse