Provider Demographics
NPI:1427412964
Name:PENDOLA BRUBAKER, FIORELLA
Entity Type:Individual
Prefix:
First Name:FIORELLA
Middle Name:
Last Name:PENDOLA BRUBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 BIG TREE DR NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5612
Mailing Address - Country:US
Mailing Address - Phone:954-684-5027
Mailing Address - Fax:253-779-8364
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-779-8364
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60943975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2145184Medicaid