Basic Information
Provider Information | |||||||||
NPI: | 1578657094 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FETHKE | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 999 N. CURTIS | ||||||||
Address2: | SUITE 205 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 83706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083731200 | ||||||||
FaxNumber: | 2083731216 | ||||||||
Practice Location | |||||||||
Address1: | 999 N. CURTIS | ||||||||
Address2: | SUITE 205 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 83706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083731200 | ||||||||
FaxNumber: | 2083731216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | M7977 | ID | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 000010029522 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | 37879 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |