Healthcare Provider Details

I. General information

NPI: 1629723200
Provider Name (Legal Business Name): DEGACHE LANDU FUKIAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2022
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 FAIRFAX BLVD
FAIRFAX VA
22030-2000
US

IV. Provider business mailing address

901 S 72ND AVE APT 223
YAKIMA WA
98908-1861
US

V. Phone/Fax

Practice location:
  • Phone: 703-679-1876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009928
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009709
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: