Basic Information
| Provider Information | |||||||||
| NPI: | 1669797049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEEN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601495 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242454 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 CALHOUN ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294011113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437242010 | ||||||||
| FaxNumber: | 8437242005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 11/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | A721 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | A721 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 721 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1583PA | 05 | SC | MEDICAID |