Provider Demographics
NPI:1447628458
Name:PERRY, KEISHA (PA)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-420-6361
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:162-337-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2024-10-07
Deactivation Date:2024-09-25
Deactivation Code:
Reactivation Date:2024-10-07
Provider Licenses
StateLicense IDTaxonomies
AZ7125363A00000X
TN2840363A00000X
VA0110006865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant