Provider Demographics
NPI:1861714875
Name:KELLER, TERRENCE JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:JOSEPH
Last Name:KELLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1964
Mailing Address - Country:US
Mailing Address - Phone:320-217-8480
Mailing Address - Fax:320-217-8490
Practice Address - Street 1:901 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1964
Practice Address - Country:US
Practice Address - Phone:320-217-8480
Practice Address - Fax:320-217-8490
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant