Basic Information
| Provider Information | |||||||||
| NPI: | 1588689491 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FASULLO | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 OLIVE WAY MSC M4-PA | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011873 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 33501 1ST WAY S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538382400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00036355 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | MA9229 | 01 | WA | BLUE SHIELD | OTHER | US1037387 | 01 | WA | AETNA/USHC SPECIALIST | OTHER | 0039577 | 01 | WA | LABOR & INDUSTRY | OTHER | 8232092 | 05 | WA | MEDICAID |