Provider Demographics
NPI:1427894856
Name:DOREMUS, KEITH A (AGACNP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:DOREMUS
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:OMER
Mailing Address - State:MI
Mailing Address - Zip Code:48749-9711
Mailing Address - Country:US
Mailing Address - Phone:734-985-4143
Mailing Address - Fax:
Practice Address - Street 1:500 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1382
Practice Address - Country:US
Practice Address - Phone:734-764-1817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704342157363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care