Healthcare Provider Details

I. General information

NPI: 1154313096
Provider Name (Legal Business Name): WALTER A FERNAU III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S DIVISION ST
SPOKANE WA
99202-1331
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-2100
  • Fax:
Mailing address:
  • Phone: 509-474-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00042789
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: