Provider Demographics
NPI:1104200625
Name:KETCHUM, ALYSSA BRIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:BRIE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:BRIE
Other - Last Name:TEASDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 1900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2986
Mailing Address - Country:US
Mailing Address - Phone:312-926-5354
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2986
Practice Address - Country:US
Practice Address - Phone:312-926-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005549363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical