Basic Information
| Provider Information | |||||||||
| NPI: | 1538495205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORASSE | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 70 N COUNTRY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740707 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4271 HEMPSTEAD TPKE STE 1 | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167963700 | ||||||||
| FaxNumber: | 5167963205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2009 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 014103 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.