Provider Demographics
NPI:1285026443
Name:FASA FAMILY WELLNESS PLLC
Entity Type:Organization
Organization Name:FASA FAMILY WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-706-2767
Mailing Address - Street 1:1610 BISHOP RD SW
Mailing Address - Street 2:STE 101
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7303
Mailing Address - Country:US
Mailing Address - Phone:360-754-3338
Mailing Address - Fax:360-753-4861
Practice Address - Street 1:3929 BRIDGEPORT WAY W STE 308
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4455
Practice Address - Country:US
Practice Address - Phone:253-272-2999
Practice Address - Fax:253-272-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8936083Medicare UPIN