Provider Demographics
NPI:1598728511
Name:FAY, MICHAEL J (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FAY
Suffix:
Gender:M
Credentials:PAC
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:122 W 7TH AVE
Practice Address - Street 2:420
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2349
Practice Address - Country:US
Practice Address - Phone:509-626-9440
Practice Address - Fax:509-626-9475
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001833363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR89182Medicare UPIN