Basic Information
| Provider Information | |||||||||
| NPI: | 1295475788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETCHERSID | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | MICAELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14100 SAN PEDRO AVE STE 412 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782322009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102818669 | ||||||||
| FaxNumber: | 2103145044 | ||||||||
| Practice Location | |||||||||
| Address1: | 12895 JOSEY LN STE 114 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752348300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725329967 | ||||||||
| FaxNumber: | 9724952287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2022 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1019995 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.