1285108514 NPI number — RAYMOND H KETCHAM FNP

Table of content: RAYMOND H KETCHAM FNP (NPI 1285108514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285108514 NPI number — RAYMOND H KETCHAM FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHAM
Provider First Name:
RAYMOND
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285108514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2326 W LAUREL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85029-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-824-9935
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7320 E DEER VALLEY RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85255-7453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-502-0250
Provider Business Practice Location Address Fax Number:
480-596-2490
Provider Enumeration Date:
01/21/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  220932 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 220932 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)