Provider Demographics
NPI:1679025902
Name:FASA FAMILY WELLNESS, PLLC
Entity Type:Organization
Organization Name:FASA FAMILY WELLNESS, PLLC
Other - Org Name:FOOT & ANKLE SURGICAL ASSOCIATES, PLLC
Other - Org Type:Doing Business As
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:SUITE 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 1:404 BLACK HILLS LN SW STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8148
Practice Address - Country:US
Practice Address - Phone:360-943-1400
Practice Address - Fax:360-943-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0-000-506-137213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty