Provider Demographics
NPI:1083639694
Name:MEDINA-DELVALLE, FERNANDO (PA C)
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:
Last Name:MEDINA-DELVALLE
Suffix:
Gender:M
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 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:509-942-2757
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003301207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349086Medicaid
WA0202692OtherLIWA
WA8349086OtherBSWA
WA8349086OtherBSWA
WAG8855779Medicare PIN