Provider Demographics
NPI:1770938532
Name:KETELSEN, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:KETELSEN
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 1:15 SANTA ROSA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1811
Mailing Address - Country:US
Mailing Address - Phone:805-541-2650
Mailing Address - Fax:805-541-4043
Practice Address - Street 1:15 SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:805-541-2650
Practice Address - Fax:805-541-4043
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB272142Medicare UPIN