Individual
MR. KEITH WESLEY FORT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2400 MOUNT ZION PKWY, KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER, JONESBORO, GA 30236-2500
(201) 943-9100
(201) 943-7308
Mailing address
3495 PIEDMONT RD NE, NINE PIEDMONT CENTER, ATLANTA, GA 30305-1717
(404) 504-5678
(201) 862-0095
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
006400
GA
363A00000X
Physician Assistant
6400
GA
363AS0400X
Surgical Physician Assistant
25MP00214500
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
162546NMS
MEDICARE PTAN
NJ
Enumeration date
05/11/2009
Last updated
01/10/2022
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