Healthcare Provider Details

I. General information

NPI: 1023712874
Provider Name (Legal Business Name): CARL ANDERSON KETCHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 PINTO LN FL 2
LAS VEGAS NV
89106-4195
US

IV. Provider business mailing address

2101 W WARM SPRINGS RD APT 3314
HENDERSON NV
89014-5517
US

V. Phone/Fax

Practice location:
  • Phone: 702-992-6888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO4137
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: