Healthcare Provider Details

I. General information

NPI: 1891901971
Provider Name (Legal Business Name): FIRCREST FAMILY MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 ALAMEDA AVE
FIRCREST WA
98466-6552
US

IV. Provider business mailing address

1339 ALAMEDA AVE
FIRCREST WA
98466-6552
US

V. Phone/Fax

Practice location:
  • Phone: 253-564-7701
  • Fax: 253-565-4688
Mailing address:
  • Phone: 253-564-7701
  • Fax: 253-565-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number601996685
License Number StateWA

VIII. Authorized Official

Name: MS. DELINDA E SHAWLES
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 253-564-7701