Healthcare Provider Details

I. General information

NPI: 1588739957
Provider Name (Legal Business Name): ANN AKIKO FUJIMOTO-DISTEFANO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 SE BISHOP BLVD STE A
PULLMAN WA
99163-5534
US

IV. Provider business mailing address

588 SE BISHOP BLVD STE A
PULLMAN WA
99163-5534
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-7778
  • Fax: 509-332-7032
Mailing address:
  • Phone: 509-332-7778
  • Fax: 509-332-7032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00009214
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8378374
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: