Healthcare Provider Details

I. General information

NPI: 1063429850
Provider Name (Legal Business Name): KENNETH D FAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12333 NE 130TH LN STE 440
KIRKLAND WA
98034-7467
US

IV. Provider business mailing address

12333 NE 130TH LN STE 440
KIRKLAND WA
98034-7467
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-3838
  • Fax: 425-899-3844
Mailing address:
  • Phone: 425-899-3838
  • Fax: 425-899-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0019926
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: