Provider Demographics
NPI:1346648367
Name:FETTERS, CHARLES RYAN (MA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RYAN
Last Name:FETTERS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 6TH AVE S
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2513
Mailing Address - Country:US
Mailing Address - Phone:206-696-3851
Mailing Address - Fax:855-272-1649
Practice Address - Street 1:5700 6TH AVE S
Practice Address - Street 2:SUITE 208
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2513
Practice Address - Country:US
Practice Address - Phone:206-696-3851
Practice Address - Fax:855-272-1649
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60306672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist