Provider Demographics
NPI:1679571475
Name:KELLER, BART R (PA-C)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:R
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 1:410 S WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-2662
Mailing Address - Country:US
Mailing Address - Phone:303-688-6900
Mailing Address - Fax:303-660-6504
Practice Address - Street 1:410 S WILCOX ST
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2662
Practice Address - Country:US
Practice Address - Phone:303-688-6900
Practice Address - Fax:303-660-6504
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002360363AS0400X
COPA.0003377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MK0941612OtherDEA
MK0941612OtherDEA
S55947Medicare UPIN