Provider Demographics
NPI:1831580430
Name:KETCHERSID, KIMBERLEE R (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:R
Last Name:KETCHERSID
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 HARTLEY WAY
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-2471
Mailing Address - Country:US
Mailing Address - Phone:540-921-6000
Mailing Address - Fax:
Practice Address - Street 1:159 HARTLEY WAY
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-2471
Practice Address - Country:US
Practice Address - Phone:540-921-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003293363A00000X
VA0110006038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant