Provider Demographics
NPI:1326477324
Name:FENTON, THOA PHAN (ARNP)
Entity Type:Individual
Prefix:DR
First Name:THOA
Middle Name:PHAN
Last Name:FENTON
Suffix:
Gender:F
Credentials:ARNP
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 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:425-261-2000
Mailing Address - Fax:425-261-4078
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60627377363LA2200X, 363LG0600X, 363L00000X
IAH124638363LA2200X
IAJ124638363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8951634Medicare UPIN