Provider Demographics
NPI:1841617164
Name:KETTERER REVOAL, BRIANA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:KETTERER REVOAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:NICOLE
Other - Last Name:KETTERER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7505 SE 22ND AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6258
Mailing Address - Country:US
Mailing Address - Phone:480-227-7075
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD467138207R00000X, 207RH0002X
ORMD177704207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine