Provider Demographics
NPI:1285704585
Name:DAMICO, KEITH CHARLES (PAC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:CHARLES
Last Name:DAMICO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:CROSSNORE
Mailing Address - State:NC
Mailing Address - Zip Code:28616-0448
Mailing Address - Country:US
Mailing Address - Phone:828-766-7278
Mailing Address - Fax:822-766-2849
Practice Address - Street 1:5235 NC 226 S
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8733
Practice Address - Country:US
Practice Address - Phone:828-766-7278
Practice Address - Fax:822-766-2849
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC102719363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89018TBMedicaid
NCP42267Medicare UPIN
NC89018TBMedicaid