Provider Demographics
NPI:1053000869
Name:KEYS, NICOLETTE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:KEYS
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 1:3031 OLIVER STREET APT #1402
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205
Mailing Address - Country:US
Mailing Address - Phone:512-363-2201
Mailing Address - Fax:
Practice Address - Street 1:1411 N BECKLEY AVE PAVILLION III SUITE 363
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203
Practice Address - Country:US
Practice Address - Phone:214-305-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant