Basic Information
| Provider Information | |||||||||
| NPI: | 1427033729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEISTER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | CAROL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 NW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973301431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417400630 | ||||||||
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| Practice Location | |||||||||
| Address1: | 527 NW 27TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | 5418475144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 229273 | 05 | OR | MEDICAID |