Provider Demographics
NPI:1548310196
Name:KELLER, DAVID WOLF (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WOLF
Last Name:KELLER
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 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7782
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:220 E BEAVER AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3103
Practice Address - Country:US
Practice Address - Phone:970-542-1707
Practice Address - Fax:970-542-1708
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0001065363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS62552Medicare UPIN