Provider Demographics
NPI:1215904081
Name:KECK, ELIA (ANP-C)
Entity type:Individual
Prefix:
First Name:ELIA
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 N US HIGHWAY 281
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2327
Mailing Address - Country:US
Mailing Address - Phone:210-614-1231
Mailing Address - Fax:210-616-0704
Practice Address - Street 1:16620 N US HIGHWAY 281
Practice Address - Street 2:STE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2327
Practice Address - Country:US
Practice Address - Phone:210-614-1231
Practice Address - Fax:210-616-0704
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254645363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173872601Medicaid
TX8B4202Medicare ID - Type Unspecified
TX173872601Medicaid