Healthcare Provider Details

I. General information

NPI: 1013945963
Provider Name (Legal Business Name): STEPHEN KETTE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7544 JACQUE RD
HUDSON FL
34667
US

IV. Provider business mailing address

7544 JACQUE RD
HUDSON FL
34667
US

V. Phone/Fax

Practice location:
  • Phone: 727-697-2200
  • Fax: 727-863-8774
Mailing address:
  • Phone: 727-697-2200
  • Fax: 727-863-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101627
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: