Provider Demographics
NPI:1467445387
Name:VETTER, WAYNE A (DPM)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:VETTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-2956
Mailing Address - Country:US
Mailing Address - Phone:503-777-3999
Mailing Address - Fax:503-777-2914
Practice Address - Street 1:5528 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2956
Practice Address - Country:US
Practice Address - Phone:503-777-3999
Practice Address - Fax:503-777-2914
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00133213E00000X
AZ0506213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR170134Medicaid
OR236182Medicaid
T68217Medicare UPIN
OR236182Medicaid