Provider Demographics
NPI:1750617072
Name:KETCHUM, SHAUNA MARIE (RPA-C)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:MARIE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:MARIE
Other - Last Name:MCCORRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:585-637-4990
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013457-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical