Provider Demographics
NPI:1174505788
Name:BERENS, KEITH A (PAC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:BERENS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 LA JOLLA
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7839
Mailing Address - Country:US
Mailing Address - Phone:850-261-8030
Mailing Address - Fax:
Practice Address - Street 1:1717 NORTH E STREET
Practice Address - Street 2:SUITE 422
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-444-7050
Practice Address - Fax:850-434-8879
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2814363A00000X
FLPA9101561363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291015200Medicaid
FL59039584OtherBSAL
FL291015200Medicaid
S83914Medicare UPIN