Basic Information
| Provider Information | |||||||||
| NPI: | 1780846279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HWANG | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | KETCHAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KETCHAM | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | SHANNON | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 E 1ST ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182495555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 920 E 1ST ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182495555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | A123578 | CA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | MD457154 | PA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 28326 | WV | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.