Provider Demographics
NPI:1891803482
Name:FETTERLEY, WALTER R II (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:R
Last Name:FETTERLEY
Suffix:II
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6354
Mailing Address - Country:US
Mailing Address - Phone:208-559-7162
Mailing Address - Fax:
Practice Address - Street 1:621 RESERVE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6354
Practice Address - Country:US
Practice Address - Phone:208-559-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-619367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807168100Medicaid
KS200576850AMedicaid
KS110017013Medicare PIN
ID1604432Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER