Provider Demographics
NPI:1134196751
Name:RUNTE, KENNAN THOMAS (DPM)
Entity type:Individual
Prefix:
First Name:KENNAN
Middle Name:THOMAS
Last Name:RUNTE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MARGARET LANE
Mailing Address - Street 2:STE B-1
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-477-7200
Mailing Address - Fax:530-477-1246
Practice Address - Street 1:123 MARGARET LANE
Practice Address - Street 2:STE B-1
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-477-7200
Practice Address - Fax:530-477-1246
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE37870213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE38771Medicaid
ZZZ06288ZOtherBS
ZZZ25759ZMedicare ID - Type Unspecified
CAE38771Medicaid