Provider Demographics
NPI:1124018254
Name:KETTL, PAUL A (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:KETTL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 NEW HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2163
Mailing Address - Country:US
Mailing Address - Phone:717-560-3782
Mailing Address - Fax:717-560-3787
Practice Address - Street 1:802 NEW HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2163
Practice Address - Country:US
Practice Address - Phone:717-560-3782
Practice Address - Fax:717-560-3787
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036495E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50048776OtherCAPITAL BLUE CROSS
PA100774OtherVALUE OPTIONS
PA0010554330003Medicaid
PA427936OtherHIGHMARK BLUE SHIELD
PA0010554330001Medicaid
PA427936JZEMedicare PIN
PA427936OtherHIGHMARK BLUE SHIELD
PA427936GFKMedicare PIN