Basic Information
| Provider Information | |||||||||
| NPI: | 1184682437 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FETT | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | OHSU DEPARTMENT OF DERMATOLOGY | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183376 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | OHSU DEPARTMENT OF DERMATOLOGY | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD162733 | OR | Y | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | 48458 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD436980 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.