Provider Demographics
NPI:1245535970
Name:KETCHNER, RICHARD E (PTA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:KETCHNER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-1518
Mailing Address - Country:US
Mailing Address - Phone:570-696-4518
Mailing Address - Fax:
Practice Address - Street 1:100 LYNWOOD AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2868
Practice Address - Country:US
Practice Address - Phone:570-346-7381
Practice Address - Fax:570-347-2443
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008832225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant