Provider Demographics
NPI:1699478123
Name:POLEON, KEISHA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:MARIE
Last Name:POLEON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 HUNTERS VILLAGE RD UNIT 361
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3809
Mailing Address - Country:US
Mailing Address - Phone:256-426-8210
Mailing Address - Fax:
Practice Address - Street 1:2919 W SWANN AVE STE 106
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4049
Practice Address - Country:US
Practice Address - Phone:813-930-2829
Practice Address - Fax:813-930-9522
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117189363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR6341OtherMEDICARE PTAN
FL118654700Medicaid
FLWN769OtherFL BLUE