Provider Demographics
NPI:1063490761
Name:FETZER, KAREN E (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:E
Last Name:FETZER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:E
Other - Last Name:VERANTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10170 SORRENTO VALLEY RD
Mailing Address - Street 2:MAILDROP SV5
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1604
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22676OtherCA MEDICAL LICENSE
CAPA22676OtherCA MEDICAL LICENSE
CAP97442Medicare UPIN