Provider Demographics
NPI:1295475788
Name:KETCHERSID, KIRSTEN MICAELA
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MICAELA
Last Name:KETCHERSID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 SAN PEDRO AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2009
Mailing Address - Country:US
Mailing Address - Phone:210-281-8669
Mailing Address - Fax:210-314-5044
Practice Address - Street 1:12895 JOSEY LN STE 114
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-8300
Practice Address - Country:US
Practice Address - Phone:972-532-9967
Practice Address - Fax:972-495-2287
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019995363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics