Basic Information
| Provider Information | |||||||||
| NPI: | 1184129447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEGAN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5513 VIRGIN ROCK RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201203311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039679924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 MANNING DR RM 1017 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741072 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2018 | ||||||||
| LastUpdateDate: | 06/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 678694 | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.