Provider Demographics
NPI:1417947813
Name:MCDERMOTT-KETCHUM, NICOLETTE (PAC)
Entity Type:Individual
Prefix:MS
First Name:NICOLETTE
Middle Name:
Last Name:MCDERMOTT-KETCHUM
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 368
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HWY 160 & MP 394.3
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20030034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61276031Medicaid
AZ803727Medicaid
NM40907503Medicaid
320059Medicare Oscar/Certification
8HBR47Medicare PIN
AZ803727Medicaid