Provider Demographics
NPI:1235194598
Name:KETTLER, PAUL A (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:KETTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1321
Mailing Address - Country:US
Mailing Address - Phone:952-892-2117
Mailing Address - Fax:952-892-2268
Practice Address - Street 1:559 CAPITOL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2101
Practice Address - Country:US
Practice Address - Phone:651-326-2400
Practice Address - Fax:651-326-2440
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1008503OtherPREFERRED ONE
MN4648605OtherAETNA
MN08F53KEOtherBCBS OF MN
MNHP17709OtherHEALTHPARTNERS
MN21983OtherAMERICA'S PPO
MN111163OtherUCARE
MN0400483OtherMEDICA
MN042717900Medicaid
MN0400483OtherMEDICA
MNG03398Medicare UPIN
MN111163OtherUCARE