Provider Demographics
NPI:1598927584
Name:FETTY, BRIAN (LMP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FETTY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14862 SE LAKE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-5821
Mailing Address - Country:US
Mailing Address - Phone:425-649-9335
Mailing Address - Fax:425-649-0256
Practice Address - Street 1:14862 SE LAKE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5821
Practice Address - Country:US
Practice Address - Phone:425-649-9335
Practice Address - Fax:425-649-0256
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006654172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist