Provider Demographics
NPI:1215965488
Name:KEATING, LARRY JOSEPH (PAC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:JOSEPH
Last Name:KEATING
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 HIGHWAY 95
Mailing Address - Street 2:SUITE G73
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7860
Mailing Address - Country:US
Mailing Address - Phone:928-758-7700
Mailing Address - Fax:928-758-5700
Practice Address - Street 1:3003 HIGHWAY 95
Practice Address - Street 2:SUITE G73
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7860
Practice Address - Country:US
Practice Address - Phone:928-758-7700
Practice Address - Fax:928-758-5700
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ62742Medicare ID - Type UnspecifiedKEATING MEDICARE NUM
AZR09321Medicare UPIN