Healthcare Provider Details

I. General information

NPI: 1245152149
Provider Name (Legal Business Name): KETCHIKAN FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 TONGASS AVE
KETCHIKAN AK
99901-5745
US

IV. Provider business mailing address

3159 TONGASS AVE
KETCHIKAN AK
99901-5745
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-4001
  • Fax: 907-225-4006
Mailing address:
  • Phone: 907-225-4001
  • Fax: 907-225-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY BETH PATTERSON
Title or Position: OWNER
Credential: APRN, FNP-C
Phone: 520-981-3725