Provider Demographics
NPI:1528164787
Name:KELLER, STEPHANIE R (PAC)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:R
Last Name:KELLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E TIMBER DR STOP 1
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-2894
Mailing Address - Country:US
Mailing Address - Phone:715-226-9232
Mailing Address - Fax:949-862-7646
Practice Address - Street 1:550 E TIMBER DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-2894
Practice Address - Country:US
Practice Address - Phone:715-226-9232
Practice Address - Fax:949-862-7646
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41980300Medicaid
Q01803Medicare UPIN
WI004437060Medicare ID - Type Unspecified