Provider Demographics
NPI:1083647606
Name:BELAY, FASSIL (PA-C)
Entity Type:Individual
Prefix:
First Name:FASSIL
Middle Name:
Last Name:BELAY
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 1:1703 S MERIDIAN STE 305
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1703 S MERIDIAN STE 305
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7590
Practice Address - Country:US
Practice Address - Phone:253-841-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004862363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00671962OtherRR MEDICARE #
WA8451080Medicaid
WA8851594Medicare PIN
WA001045700Medicare PIN
WAG8880511Medicare UPIN
WAG8851595Medicare PIN
WA000188100Medicare PIN
WAP00671962OtherRR MEDICARE #
WA8451080Medicaid
WA8869563Medicare PIN
WAG8851597Medicare PIN
WA8869564Medicare PIN