Provider Demographics
NPI:1801895610
Name:FETTERLY, PAUL J (MD, FACOG)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:FETTERLY
Suffix:
Gender:M
Credentials:MD, FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-1100
Mailing Address - Country:US
Mailing Address - Phone:701-662-2157
Mailing Address - Fax:701-662-4116
Practice Address - Street 1:1001 7TH ST NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2719
Practice Address - Country:US
Practice Address - Phone:701-662-2157
Practice Address - Fax:701-662-4116
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18821Medicaid
G27218Medicare UPIN
ND18821Medicaid