Provider Demographics
NPI:1396997110
Name:KEETER, NICOLE C (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:C
Last Name:KEETER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 1ST BAXTER XING STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8950
Mailing Address - Country:US
Mailing Address - Phone:803-802-3376
Mailing Address - Fax:803-802-3329
Practice Address - Street 1:1700 1ST BAXTER XING STE 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8950
Practice Address - Country:US
Practice Address - Phone:803-802-3376
Practice Address - Fax:803-802-3329
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003081363A00000X
DCPA030560363A00000X
SCTL3251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant