Provider Demographics
NPI:1194883512
Name:KEEHN, DIANE M (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:KEEHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:WILKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11051 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-3354
Mailing Address - Fax:608-884-5022
Practice Address - Street 1:11051 N SHERMAN RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9002
Practice Address - Country:US
Practice Address - Phone:608-884-3354
Practice Address - Fax:608-884-5022
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1456363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194883512Medicaid
IL002190254Medicaid
S63198Medicare UPIN
S63198Medicare UPIN