Provider Demographics
NPI:1629723200
Name:FUKIAU, DEGACHE LANDU
Entity type:Individual
Prefix:
First Name:DEGACHE
Middle Name:LANDU
Last Name:FUKIAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 72ND AVE APT 223
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-1861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10100 FAIRFAX BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2000
Practice Address - Country:US
Practice Address - Phone:703-679-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-13
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant