Basic Information
| Provider Information | |||||||||
| NPI: | 1316592637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEENAN | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 W JOHN ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618213512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176371310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 819 BLOOMINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618202101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173561558 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2019 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085007149 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.