Provider Demographics
NPI:1710762588
Name:KEEN, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KEEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 CLIFTON RD NE STE 280
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1063
Mailing Address - Country:US
Mailing Address - Phone:404-727-7825
Mailing Address - Fax:
Practice Address - Street 1:201 E LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:WOODLAKE
Practice Address - State:CA
Practice Address - Zip Code:93286-1301
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant