Provider Demographics
NPI:1265498901
Name:DE IMUS, FA ABIGAIL C (MD)
Entity Type:Individual
Prefix:
First Name:FA ABIGAIL
Middle Name:C
Last Name:DE IMUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:C
Other - Last Name:DE IMUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:2901 174TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-4743
Practice Address - Country:US
Practice Address - Phone:360-454-1941
Practice Address - Fax:360-454-1991
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA38739207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006353Medicaid
C45382Medicare UPIN
AB40104Medicare PIN