MEDICARE: ERIC JAMES FASTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1972002665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC JAMES FASTH

Provider Business Mailing Address
First Line	:	664 SW TAFT ST
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-6628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 SW BRUMBACK ST UNIT 2035
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-6899
Country	:	US
Telephone Number	:	208-943-1864
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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