Provider Demographics
NPI:1114901113
Name:FARIA, RUSSELL WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:FARIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 M ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4503
Mailing Address - Country:US
Mailing Address - Phone:253-735-0260
Mailing Address - Fax:253-735-0245
Practice Address - Street 1:721 M ST NE STE 100
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4503
Practice Address - Country:US
Practice Address - Phone:253-735-0260
Practice Address - Fax:253-735-0245
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR911835477OtherFEDERAL TAX ID NUMBER
ORC39126Medicare UPIN