Provider Demographics
NPI:1265983787
Name:KETCHERSID, ANTHONY (PMHNP)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KETCHERSID
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4219
Mailing Address - Country:US
Mailing Address - Phone:940-723-4488
Mailing Address - Fax:940-723-4490
Practice Address - Street 1:6515 KEMP BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-5419
Practice Address - Country:US
Practice Address - Phone:940-692-1220
Practice Address - Fax:940-689-5108
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132307363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health