Healthcare Provider Details

I. General information

NPI: 1174594899
Provider Name (Legal Business Name): EDUARDO ROBERTO FAYTONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-3926
US

IV. Provider business mailing address

1019 PACIFIC AVE STE 300
TACOMA WA
98402-4488
US

V. Phone/Fax

Practice location:
  • Phone: 253-597-4550
  • Fax: 253-722-1546
Mailing address:
  • Phone: 253-597-4550
  • Fax: 253-722-1546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60688816
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: