Provider Demographics
NPI:1730517731
Name:KELLER, GLORIA (PA-C)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
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 1:2851 S AVE B
Mailing Address - Street 2:STE 201
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2851 S AVENUE B
Practice Address - Street 2:STE 201
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-726-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant