Healthcare Provider Details

I. General information

NPI: 1467431726
Provider Name (Legal Business Name): FAMILY PRACTICE ASSOCIATES OF WALLA WALLA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 10/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 S 2ND AVE SUITE 2
WALLA WALLA WA
99362-4183
US

IV. Provider business mailing address

PO BOX 1663
WALLA WALLA WA
99362-0031
US

V. Phone/Fax

Practice location:
  • Phone: 509-522-0606
  • Fax:
Mailing address:
  • Phone: 509-529-1284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00018950
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30002544
License Number StateWA

VIII. Authorized Official

Name: DALE T FETROE
Title or Position: OWNER
Credential: MD
Phone: 509-522-0606