Provider Demographics
NPI:1215047766
Name:KECK, JOHN ROBERT (NP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:KECK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5101
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-253-8891
Practice Address - Street 1:6376 W BELL RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3602
Practice Address - Country:US
Practice Address - Phone:623-486-8202
Practice Address - Fax:623-486-2739
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN083769363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106815Medicare ID - Type Unspecified
AZQ57565Medicare UPIN