Provider Demographics
NPI:1386344471
Name:JOHNSTON, KEELIE (PA-C)
Entity type:Individual
Prefix:
First Name:KEELIE
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEELIE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222 STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3204
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-628-0468
Practice Address - Street 1:1038 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2044
Practice Address - Country:US
Practice Address - Phone:903-593-9474
Practice Address - Fax:903-593-9477
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant