Provider Demographics
NPI:1528671831
Name:AMARA, KEKELI DIANE OMINIRA (PA-C)
Entity type:Individual
Prefix:MS
First Name:KEKELI
Middle Name:DIANE OMINIRA
Last Name:AMARA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEKELI-DIANE
Other - Middle Name:
Other - Last Name:ATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2669
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10163-2669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 ELKTON PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-2517
Practice Address - Country:US
Practice Address - Phone:513-919-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant