Healthcare Provider Details

I. General information

NPI: 1114901113
Provider Name (Legal Business Name): RUSSELL WILLIAM FARIA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 11/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 M ST NE STE 100
AUBURN WA
98002-4503
US

IV. Provider business mailing address

721 M ST NE STE 100
AUBURN WA
98002-4503
US

V. Phone/Fax

Practice location:
  • Phone: 253-735-0260
  • Fax: 253-735-0245
Mailing address:
  • Phone: 253-735-0260
  • Fax: 253-735-0245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001307
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: