Provider Demographics
NPI:1164531794
Name:STETLER, THOMAS KEANE (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:KEANE
Last Name:STETLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4713 PINE ST SW
Mailing Address - Street 2:
Mailing Address - City:S BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9761
Mailing Address - Country:US
Mailing Address - Phone:231-518-0189
Mailing Address - Fax:231-518-0188
Practice Address - Street 1:4713 PINE ST SW
Practice Address - Street 2:
Practice Address - City:S BOARDMAN
Practice Address - State:MI
Practice Address - Zip Code:49680-9761
Practice Address - Country:US
Practice Address - Phone:231-518-0189
Practice Address - Fax:231-518-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant