Provider Demographics
NPI:1316333107
Name:KEENAN, KARISSA DEANN (MD)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:DEANN
Last Name:KEENAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KARISSA
Other - Middle Name:
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-1200
Mailing Address - Fax:208-302-1255
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-1200
Practice Address - Fax:208-302-1255
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10100582-1205207V00000X
UT10100582-8905207V00000X
390200000X
IDM-14675207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10100582-1205OtherUTAH LICENSE
UT10100582-8905OtherUTAH CS SCHEDULE