Provider Demographics
NPI:1689411977
Name:DEVORE, MICHAEL FAUSTINO
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FAUSTINO
Last Name:DEVORE
Suffix:
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 1:3632 RUCKER AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-5118
Mailing Address - Country:US
Mailing Address - Phone:619-701-2375
Mailing Address - Fax:
Practice Address - Street 1:809 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2172
Practice Address - Country:US
Practice Address - Phone:206-745-2754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist