Provider Demographics
NPI:1104390921
Name:RITCHIE, KEITH BACON (PA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:BACON
Last Name:RITCHIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-4547
Mailing Address - Country:US
Mailing Address - Phone:508-760-5318
Mailing Address - Fax:
Practice Address - Street 1:76 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-4547
Practice Address - Country:US
Practice Address - Phone:508-760-5318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant