Provider Demographics
NPI:1881684272
Name:KETCHUM, ARNOLD (PA-C)
Entity Type:Individual
Prefix:
First Name:ARNOLD
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:PA-C
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:928-697-4000
Mailing Address - Fax:928-697-4145
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:928-697-4145
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NMPA20030033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ697609Medicaid
NM67509312Medicaid
CO90635256Medicaid
P36526Medicare UPIN
NM67509312Medicaid
CO90635256Medicaid
8HC943Medicare PIN
8HC942Medicare PIN