Provider Demographics
NPI:1558334243
Name:WINTERS, KEITH D (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:WINTERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 400
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:13555 W MCDOWELL RD
Practice Address - Street 2:SUITE 304
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2624
Practice Address - Country:US
Practice Address - Phone:623-935-5522
Practice Address - Fax:623-935-3220
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ742909Medicaid
AZZ108715Medicare PIN
AZ742909Medicaid