Provider Demographics
NPI:1568438562
Name:KERSTEN, TYCHO E (MD)
Entity type:Individual
Prefix:
First Name:TYCHO
Middle Name:E
Last Name:KERSTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 W 5TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2715
Mailing Address - Country:US
Mailing Address - Phone:509-344-2663
Mailing Address - Fax:509-624-9179
Practice Address - Street 1:601 W 5TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2715
Practice Address - Country:US
Practice Address - Phone:509-344-2663
Practice Address - Fax:509-624-9179
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039855207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA200040948OtherRR MEDICARE
WA379109600OtherOWCP
WA5030KEOtherASURIS NW HEALTH
WA8928289OtherCRIME VICTIMS
IDKQ803OtherBLUE CROSS OF IDAHO
WA22669OtherGROUP HEALTH NW
ID806017400Medicaid
ID000010135813OtherREGENCE BLUE SHIELD
WA0149631OtherDEPT OF LABOR & INDUSTRIE
WA8276586Medicaid
WA0149631OtherDEPT OF LABOR & INDUSTRIE
AB24188Medicare PIN
ID000010135813OtherREGENCE BLUE SHIELD