Provider Demographics
NPI:1205128543
Name:KETTERL, TYLER GARRETT (MD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:GARRETT
Last Name:KETTERL
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 1:4800 SAND POINT WAY NE, MS: MB.8.501
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-987-2106
Mailing Address - Fax:206-987-3946
Practice Address - Street 1:4800 SAND POINT WAY NE, MS: MB.8.501
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2106
Practice Address - Fax:206-987-3946
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60552603207R00000X, 2080P0207X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program