Provider Demographics
NPI:1215932702
Name:KEAVEY, SANDRA M (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:KEAVEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:M
Other - Last Name:SHELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16351 ROTUNDA DR
Mailing Address - Street 2:#275D
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1170
Mailing Address - Country:US
Mailing Address - Phone:910-709-1488
Mailing Address - Fax:
Practice Address - Street 1:32605 W 12 MILE RD STE 195
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3390
Practice Address - Country:US
Practice Address - Phone:313-306-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001357363A00000X
NC0010-03212363A00000X
WAPA60467722363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISK001357OtherSTATE LICENSE
NC0010-03212OtherSTATE LICENSE
MIN98340001OtherMEDICARE
MISK001357OtherSTATE LICENSE
MIS91474Medicare UPIN