Provider Demographics
NPI:1225126915
Name:DECATO, EDMUND JOSEPH (PA-SA)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:JOSEPH
Last Name:DECATO
Suffix:
Gender:M
Credentials:PA-SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-0353
Mailing Address - Country:US
Mailing Address - Phone:425-788-7687
Mailing Address - Fax:425-788-7687
Practice Address - Street 1:31426 NE 108TH ST
Practice Address - Street 2:
Practice Address - City:CARNATION
Practice Address - State:WA
Practice Address - Zip Code:98014-9731
Practice Address - Country:US
Practice Address - Phone:425-788-7687
Practice Address - Fax:425-788-7687
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002121363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR30133Medicare UPIN
WAAB22945Medicare ID - Type UnspecifiedBELLEVUE ORTHO
WA8852916Medicare ID - Type UnspecifiedBADGER