Healthcare Provider Details

I. General information

NPI: 1760476352
Provider Name (Legal Business Name): RENATO VERANO FAJARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34616 11TH PL S #3
FEDERAL WAY WA
98003-8705
US

IV. Provider business mailing address

34616 11TH PL S STE 3
FEDERAL WAY WA
98003-8705
US

V. Phone/Fax

Practice location:
  • Phone: 253-874-5148
  • Fax: 253-874-4228
Mailing address:
  • Phone: 253-874-5148
  • Fax: 253-874-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30962
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: