Provider Demographics
NPI:1093741613
Name:KETCHIN, NICOLE PERRIN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:PERRIN
Last Name:KETCHIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:180 WINGO WAY
Practice Address - Street 2:SUITE 307
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1810
Practice Address - Country:US
Practice Address - Phone:843-884-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1073363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0363PAMedicaid
SC0363PAMedicaid
SCAA1139Medicare UPIN