Provider Demographics
NPI:1003854902
Name:FAYETTE, BARBARA R (PA C)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:R
Last Name:FAYETTE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:21601 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7507
Practice Address - Country:US
Practice Address - Phone:425-640-4000
Practice Address - Fax:425-640-4010
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190248OtherLIWA
WA0259FAOtherLIWA
WA2595FAOtherBSWA
WA0220106OtherLIWA
WA8364093Medicaid
WA1051FAOtherBSWA
WA8364093Medicaid
WAG8862502Medicare PIN
WA0220106OtherLIWA
WA2595FAOtherBSWA
WAG8864987Medicare PIN
WAP00366409Medicare PIN