Provider Demographics
NPI:1225701600
Name:FENOLI, RYAN MATTHEW
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:FENOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7718 NE 151ST LN
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-5600
Mailing Address - Country:US
Mailing Address - Phone:425-638-9730
Mailing Address - Fax:
Practice Address - Street 1:505 S 336TH ST STE 500
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8300
Practice Address - Country:US
Practice Address - Phone:657-400-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant