1003854902 NPI number — BARBARA R FAYETTE PA C

Table of content: BARBARA R FAYETTE PA C (NPI 1003854902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003854902 NPI number — BARBARA R FAYETTE PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAYETTE
Provider First Name:
BARBARA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003854902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 S 336TH ST
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-6328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-838-6180
Provider Business Mailing Address Fax Number:
253-838-6418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21601 76TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-640-4000
Provider Business Practice Location Address Fax Number:
425-640-4010
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10003948 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0190248 . This is a "LIWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0259FA . This is a "LIWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2595FA . This is a "BSWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0220106 . This is a "LIWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8364093 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1051FA . This is a "BSWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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