Provider Demographics
NPI:1730197211
Name:BULLER, KEITH A (PA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:BULLER
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 1:1701 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8911
Mailing Address - Country:US
Mailing Address - Phone:337-494-3000
Mailing Address - Fax:
Practice Address - Street 1:1701 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8911
Practice Address - Country:US
Practice Address - Phone:337-494-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200007.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAQ33158Medicare UPIN
GAPENDINGMedicaid