Healthcare Provider Details

I. General information

NPI: 1104519461
Provider Name (Legal Business Name): MCKENON VICTOR ABREU DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12109 E BROADWAY AVE STE C
SPOKANE VALLEY WA
99206-6133
US

IV. Provider business mailing address

13802 JAKE RD
VALLEY CENTER CA
92082-5819
US

V. Phone/Fax

Practice location:
  • Phone: 509-928-1990
  • Fax:
Mailing address:
  • Phone: 760-807-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO70116639
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: