Provider Demographics
NPI:1679979769
Name:FASA FAMILY WELLNESS PLLC
Entity Type:Organization
Organization Name:FASA FAMILY WELLNESS PLLC
Other - Org Name:
Other - Org Type:
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 STE 101
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7303
Mailing Address - Country:US
Mailing Address - Phone:360-338-0004
Mailing Address - Fax:360-515-0744
Practice Address - Street 1:1220 W 1ST ST
Practice Address - Street 2:SUITE B
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3018
Practice Address - Country:US
Practice Address - Phone:360-736-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty