Provider Demographics
NPI:1790664068
Name:PLACENCIA, FORTUNATO JR
Entity type:Individual
Prefix:
First Name:FORTUNATO
Middle Name:
Last Name:PLACENCIA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:CASHMERE
Mailing Address - State:WA
Mailing Address - Zip Code:98815-1052
Mailing Address - Country:US
Mailing Address - Phone:509-881-4395
Mailing Address - Fax:
Practice Address - Street 1:6808 220TH ST SW STE 201
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2187
Practice Address - Country:US
Practice Address - Phone:425-640-6976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant