Provider Demographics
NPI:1881647717
Name:PETTET, MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PETTET
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11516 SE MILL PLAIN BLVD
Mailing Address - Street 2:STE 2C
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5082
Mailing Address - Country:US
Mailing Address - Phone:360-253-6674
Mailing Address - Fax:360-253-8670
Practice Address - Street 1:11600 SE MILL PLAIN BLVD
Practice Address - Street 2:SUITE 3J
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5083
Practice Address - Country:US
Practice Address - Phone:360-253-6674
Practice Address - Fax:360-253-8670
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034021111N00000X
OR283284111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB34331Medicare ID - Type Unspecified
AB34343Medicare ID - Type Unspecified
U88112Medicare UPIN