Provider Demographics
NPI:1407248214
Name:KETSAN, KEVIN (NP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KETSAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 MARY CMN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3474
Mailing Address - Country:US
Mailing Address - Phone:877-830-7328
Mailing Address - Fax:877-830-7469
Practice Address - Street 1:2414 S. FAIRVIEW ST.
Practice Address - Street 2:SUITE 212
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:877-830-7328
Practice Address - Fax:877-830-7469
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000775363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health