Provider Demographics
NPI:1972728194
Name:KEELER, TIMOTHY P (PA-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:P
Last Name:KEELER
Suffix:
Gender:M
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 1:111 E WACKERLY ST STE D
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-7043
Mailing Address - Country:US
Mailing Address - Phone:989-495-2050
Mailing Address - Fax:989-495-2095
Practice Address - Street 1:111 E WACKERLY ST STE D
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-7043
Practice Address - Country:US
Practice Address - Phone:989-495-2050
Practice Address - Fax:989-495-2095
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002258363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS57348Medicare UPIN
MIN99790017Medicare ID - Type Unspecified