Basic Information
| Provider Information | |||||||||
| NPI: | 1013332246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEENE | ||||||||
| FirstName: | KASEY | ||||||||
| MiddleName: | POMPOSELLI | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 3417 GASTON AVE | ||||||||
| Address2: | SUITE 830 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752460830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148266021 | ||||||||
| FaxNumber: | 2148239745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2014 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA08280 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 332760302 | 05 | TX | MEDICAID |