Provider Demographics
NPI:1528269743
Name:FETSCH, CHRISTIAN FREDERICK (LAC, MSTCM)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:FREDERICK
Last Name:FETSCH
Suffix:
Gender:M
Credentials:LAC, MSTCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 ALDINE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2271
Mailing Address - Country:US
Mailing Address - Phone:612-871-2288
Mailing Address - Fax:
Practice Address - Street 1:100 W 46TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-4950
Practice Address - Country:US
Practice Address - Phone:612-871-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1246171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist