Provider Demographics
NPI:1093422388
Name:KETCHUM, KRISTOPHER CASEY (CERTIFIED PEDORTHIST)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:CASEY
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:CERTIFIED PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31863 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8422
Mailing Address - Country:US
Mailing Address - Phone:269-873-3541
Mailing Address - Fax:
Practice Address - Street 1:31863 29TH ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8422
Practice Address - Country:US
Practice Address - Phone:269-873-3541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3509224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist