Provider Demographics
NPI:1295305399
Name:KETTER, BENJAMIN L (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:KETTER
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 1:1601 SAUNDERS CRES
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2535
Mailing Address - Country:US
Mailing Address - Phone:785-221-5965
Mailing Address - Fax:
Practice Address - Street 1:7272 N SHELDON RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2150
Practice Address - Country:US
Practice Address - Phone:877-882-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant