Healthcare Provider Details

I. General information

NPI: 1639081615
Provider Name (Legal Business Name): PETER FUQUA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 SE 189TH AVE
VANCOUVER WA
98683-5708
US

IV. Provider business mailing address

753 N 35TH ST # 208D
SEATTLE WA
98103-8870
US

V. Phone/Fax

Practice location:
  • Phone: 206-462-5830
  • Fax:
Mailing address:
  • Phone: 206-462-5830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: