Provider Demographics
NPI:1063584498
Name:KETTERER, DEBORAH JEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:JEAN
Last Name:KETTERER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 TALBOT RD S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-271-1351
Mailing Address - Fax:425-271-1368
Practice Address - Street 1:4361 TALBOT RD S
Practice Address - Street 2:SUITE 101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-271-1351
Practice Address - Fax:425-271-1368
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000470213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106186Medicaid
U21759Medicare UPIN