Provider Demographics
NPI:1316944812
Name:KELLER, DEBRA ROY (PA)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:ROY
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-368-4000
Mailing Address - Fax:585-225-2685
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-368-4000
Practice Address - Fax:585-225-2685
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400015825/70008A GPMedicare PIN
NYJ400017352/BA0017 GPMedicare PIN