Provider Demographics
NPI:1376189308
Name:KIRBOW, KEITH ALLEN (APRN, FNP-C, PMHNP-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:KIRBOW
Suffix:
Gender:M
Credentials:APRN, FNP-C, PMHNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 HACK BERRY RD
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-8432
Mailing Address - Country:US
Mailing Address - Phone:903-806-1060
Mailing Address - Fax:
Practice Address - Street 1:1300 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5567
Practice Address - Country:US
Practice Address - Phone:903-921-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144151363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health