Healthcare Provider Details

I. General information

NPI: 1861495640
Provider Name (Legal Business Name): FASA FAMILY WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 BROADWAY ST
LONGVIEW WA
98632-3842
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-3682
  • Fax: 360-577-1871
Mailing address:
  • Phone: 360-577-3682
  • Fax: 360-577-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000488
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TERRENCE EUGENE HESS
Title or Position: OWNER
Credential:
Phone: 360-754-3338