Basic Information
| Provider Information | |||||||||
| NPI: | 1083647606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELAY | ||||||||
| FirstName: | FASSIL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 S MERIDIAN STE 305 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717590 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1703 S MERIDIAN STE 305 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10004862 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA10004862 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00671962 | 01 | WA | RR MEDICARE # | OTHER | 8451080 | 05 | WA | MEDICAID |