Healthcare Provider Details

I. General information

NPI: 1891749248
Provider Name (Legal Business Name): WALTER R. FENNING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21601 76TH AVE W
EDMONDS WA
98026-7507
US

IV. Provider business mailing address

1954 FORT UNION BLVD STE 119
SALT LAKE CITY UT
84121-6994
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-4000
  • Fax: 206-672-0211
Mailing address:
  • Phone: 866-910-6157
  • Fax: 801-733-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00020794
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD00020794
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: