Provider Demographics
NPI:1417371600
Name:KEENE, KRISTIE (PA)
Entity type:Individual
Prefix:MS
First Name:KRISTIE
Middle Name:
Last Name:KEENE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:GENSHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-4715
Mailing Address - Fax:585-922-3950
Practice Address - Street 1:1415 PORTLAND AVE STE 245
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3022
Practice Address - Country:US
Practice Address - Phone:585-922-4715
Practice Address - Fax:585-922-3950
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017293363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical