Provider Demographics
NPI:1700444650
Name:TAILLIE, KEITH THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:THOMAS
Last Name:TAILLIE
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 1:566 PUTNAM AVE APT 2L
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4870
Mailing Address - Country:US
Mailing Address - Phone:585-362-9451
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6106
Practice Address - Country:US
Practice Address - Phone:585-362-9451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPA7031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant