Provider Demographics
NPI:1760541734
Name:FETHERSTON, DEBRA SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:SUSAN
Last Name:FETHERSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:SUSAN
Other - Last Name:SIKORSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:275 BRONSON WAY NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-4030
Mailing Address - Country:US
Mailing Address - Phone:206-718-1540
Mailing Address - Fax:425-222-4763
Practice Address - Street 1:275 BRONSON WAY NE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4030
Practice Address - Country:US
Practice Address - Phone:425-235-2800
Practice Address - Fax:425-222-4763
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA28613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8130940Medicaid
BG9446Medicare UPIN
WA8130940Medicaid
WAG8881532Medicare PIN