Provider Demographics
NPI:1982803417
Name:FETTERS, SHAE (CFA)
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:
Last Name:FETTERS
Suffix:
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 N UNIVERSITY AVE # 123
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4405
Mailing Address - Country:US
Mailing Address - Phone:801-319-0371
Mailing Address - Fax:
Practice Address - Street 1:3214 N UNIVERSITY AVE # 123
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4405
Practice Address - Country:US
Practice Address - Phone:801-319-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist