Provider Demographics
NPI:1649405226
Name:FETTY, SCOTT WARREN (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WARREN
Last Name:FETTY
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 1:11700 MUKILTEO SPEEDWAY STE 201-1142
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5432
Mailing Address - Country:US
Mailing Address - Phone:206-354-9335
Mailing Address - Fax:
Practice Address - Street 1:11700 MUKILTEO SPEEDWAY STE 201-1142
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5432
Practice Address - Country:US
Practice Address - Phone:206-719-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60342809208000000X, 207R00000X
OK27107208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics