Provider Demographics
NPI:1568438562
Name:KERSTEN, TYCHO E (MD)
Entity Type:Individual
Prefix:
First Name:TYCHO
Middle Name:E
Last Name:KERSTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 5TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2715
Mailing Address - Country:US
Mailing Address - Phone:509-344-2663
Mailing Address - Fax:509-624-9179
Practice Address - Street 1:601 W 5TH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2715
Practice Address - Country:US
Practice Address - Phone:509-344-2663
Practice Address - Fax:509-624-9179
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00039855207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA379109600OtherOWCP
WA8276586Medicaid
WA22669OtherGROUP HEALTH NW
WA0149631OtherDEPT OF LABOR & INDUSTRIE
WA5030KEOtherASURIS NW HEALTH
ID806017400Medicaid
WA8928289OtherCRIME VICTIMS
ID000010135813OtherREGENCE BLUE SHIELD
WA200040948OtherRR MEDICARE
IDKQ803OtherBLUE CROSS OF IDAHO
WA0149631OtherDEPT OF LABOR & INDUSTRIE
AB24188Medicare PIN
ID000010135813OtherREGENCE BLUE SHIELD