Provider Demographics
NPI:1174505788
Name:BERENS, KEITH A (PAC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:BERENS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:801-784-0954
Mailing Address - Fax:801-352-7976
Practice Address - Street 1:125 BAPTIST WAY STE 4C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2274
Practice Address - Country:US
Practice Address - Phone:448-227-6330
Practice Address - Fax:850-626-9606
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101561363AS0400X
NH2814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291015200Medicaid
FL59039584OtherBSAL
FL291015200Medicaid
S83914Medicare UPIN