Provider Demographics
NPI:1225770670
Name:KETCHUM, NEAL DEXTER
Entity type:Individual
Prefix:
First Name:NEAL
Middle Name:DEXTER
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PARNASSUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2203
Mailing Address - Country:US
Mailing Address - Phone:415-883-0944
Mailing Address - Fax:415-476-9516
Practice Address - Street 1:500 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2203
Practice Address - Country:US
Practice Address - Phone:415-883-0944
Practice Address - Fax:415-476-9516
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA826887163W00000X
390200000X
CA95001818367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program