Provider Demographics
NPI:1942209366
Name:KETCHUM, LYNN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:DANIEL
Last Name:KETCHUM
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 1:11111 NALL AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1925
Mailing Address - Country:US
Mailing Address - Phone:913-451-8567
Mailing Address - Fax:913-451-8568
Practice Address - Street 1:11111 NALL AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1925
Practice Address - Country:US
Practice Address - Phone:913-451-8567
Practice Address - Fax:913-451-8568
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-14119174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000026293OtherBCBS OF KANSAS
KS07649010OtherBCBS OF KANSAS CITY
KS5880938Medicare ID - Type Unspecified
KS0000026293OtherBCBS OF KANSAS