Basic Information
| Provider Information | |||||||||
| NPI: | 1760862619 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KELLER | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | SUITE A721 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163913139 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 10002169A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 5601007414 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.