Healthcare Provider Details

I. General information

NPI: 1902864630
Provider Name (Legal Business Name): DEWAYNE LEE ENYEART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 ENSIGN RD NE STE B
OLYMPIA WA
98506-5074
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number18783
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: