MEDICARE: TRYSTIN A KETCHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	PT29457	FL
2	225100000X	Physical Therapist	PT29457	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023427366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRYSTIN A KETCHAM

Provider Business Mailing Address
First Line	:	13530 WEYBURNE DR
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33446-3648
Country	:	US
Telephone Number	:	561-866-1935
Fax Number	:

Provider Business Practice Location Address
First Line	:	13530 WEYBURNE DR
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33446-3648
Country	:	US
Telephone Number	:	561-866-1935
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	03/14/2023

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Directions to “ TRYSTIN A KETCHAM ” Practice Location

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