Provider Demographics
NPI:1841276946
Name:KETCHEM, SUSAN MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:KETCHEM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MCCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416-8076
Mailing Address - Country:US
Mailing Address - Phone:304-457-2800
Mailing Address - Fax:304-457-4011
Practice Address - Street 1:116 MCCLELLAN RD
Practice Address - Street 2:
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416-8076
Practice Address - Country:US
Practice Address - Phone:304-457-2800
Practice Address - Fax:304-457-4011
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01397363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1841276946OtherMT STATE BC/BS
WVWV01397OtherTHE HEALTH PLAN
WV3810000464Medicaid
WV3810000464Medicaid
WVMK0702248OtherDEA
WVWV01397OtherTHE HEALTH PLAN