Healthcare Provider Details

I. General information

NPI: 1710096615
Provider Name (Legal Business Name): ASUQUO A ESUABANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 MEMORIAL ST
PROSSER WA
99350-1524
US

IV. Provider business mailing address

PO BOX 4913
FEDERAL WAY WA
98063-4913
US

V. Phone/Fax

Practice location:
  • Phone: 509-786-2307
  • Fax:
Mailing address:
  • Phone: 253-874-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00033898
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00033898
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: