Healthcare Provider Details

I. General information

NPI: 1366510745
Provider Name (Legal Business Name): FIDALGO SPORTS AND PHYSIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 32ND ST SUITE B
ANACORTES WA
98221-3473
US

IV. Provider business mailing address

912 32ND ST SUITE B
ANACORTES WA
98221-3473
US

V. Phone/Fax

Practice location:
  • Phone: 360-293-5603
  • Fax: 360-293-6594
Mailing address:
  • Phone: 360-293-5603
  • Fax: 360-293-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD32852
License Number StateWA

VIII. Authorized Official

Name: DR. DEBORAH ELLEN AMOS
Title or Position: OWNER
Credential: MD
Phone: 360-293-5603