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General NPI Number Information
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NPI Number | 1629723200
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Entity Type | Individual
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Provider Name | DEGACHE LANDU FUKIAU
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Gender | Male
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Dates
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Enumeration Date | 02/13/2022
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Last Update Date | 07/21/2025
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Provider Practice Location Address
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Address Line | 10100 FAIRFAX BLVD
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City | FAIRFAX
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State | VA
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Zip | 22030-2000
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Country | US
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Telephone | 703-679-1876
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Fax |
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Provider Business Mailing Address
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Address Line | 901 S 72ND AVE APT 223
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City | YAKIMA
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State | WA
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Zip | 98908-1861
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C0009928
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110009709
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License Number State | VA
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