Provider Demographics
NPI:1487996849
Name:KETCHUM, KATHLEEN ANNE (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:KETCHUM
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 1:1 S KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7199
Mailing Address - Country:US
Mailing Address - Phone:573-443-2402
Mailing Address - Fax:573-443-0574
Practice Address - Street 1:1 S KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7199
Practice Address - Country:US
Practice Address - Phone:573-443-2402
Practice Address - Fax:573-443-0574
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013005293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant