Basic Information
| Provider Information | |||||||||
| NPI: | 1134308067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KECK | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MPA,PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CARILLON POINT | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980337306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255761700 | ||||||||
| FaxNumber: | 4258277725 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CARILLON PT | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980337306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255761700 | ||||||||
| FaxNumber: | 4258277725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2007 | ||||||||
| LastUpdateDate: | 09/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1187 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60021277 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200536260A | 05 | KS | MEDICAID |