Provider Demographics
NPI:1568449288
Name:FACKENTHALL, JOHN ANTON (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTON
Last Name:FACKENTHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 E ISAACS AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2152
Mailing Address - Country:US
Mailing Address - Phone:509-525-4100
Mailing Address - Fax:
Practice Address - Street 1:1312 E ISAACS AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2152
Practice Address - Country:US
Practice Address - Phone:509-252-4100
Practice Address - Fax:509-529-7033
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8850948OtherMEDICARE GROUP PIN
WA1252808Medicaid
WA8851221Medicare ID - Type Unspecified
WAG8850948OtherMEDICARE GROUP PIN