John Anton Fackenthall, D.O.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

OP00000703 Issued in WA

Practice address

1312 E Isaacs Ave
Walla Walla, WA 99362-2152

Phone

(509) 252-4100

Fax

(509) 529-7033

NPI assigned

Dec 22, 2005

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135209600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1357171200000",
    "number": "1568449288",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1312 E ISAACS AVE",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993622152",
            "telephone_number": "509-525-4100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1312 E ISAACS AVE",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993622152",
            "telephone_number": "509-252-4100",
            "fax_number": "509-529-7033"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FACKENTHALL",
        "first_name": "JOHN",
        "middle_name": "ANTON",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-12-22",
        "last_updated": "2013-01-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "OP00000703",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP PIN",
            "identifier": "G8850948",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1252808",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Levi A Evans, MD
• Amy Evensen, MA
• Kaitlyn Everson, OTR/L
• Eye & Laser Physicians of Walla Walla
• Chelane R Fackenthall, ARNP
• Travis Christoph Fagala, DENTURIST
• Cynthia Marie Failor, RN
• Jennings C Falcon II, MD
• Family Acupuncture & Wellness LLC
• Family Practice Associates of Walla Walla PLLC

• Family Medicine Physician in Walla Walla, WA
• Providers in Walla Walla, WA by specialty
• Family Medicine Physician in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.