Individual
MR. WALTER R FETTERLEY II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
621 RESERVE ST, BOISE, ID 83712-6354
(208) 559-7162
Mailing address
621 RESERVE ST, BOISE, ID 83712-6354
(208) 559-7162
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
RNA-619
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200576850A
—
KS
05
—
807168100
—
ID
Enumeration date
08/25/2006
Last updated
11/20/2008
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