Provider Demographics
NPI:1215446869
Name:KELLER, KIERA (PA-C)
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BRANFORD RD
Mailing Address - Street 2:
Mailing Address - City:WHIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07981-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S ORANGE AVE STE 170
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:973-867-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021414Medicaid
NJ25MP00452400Medicaid