Provider Demographics
NPI:1447302658
Name:GUNNINGHAM, FREDERICK JOHN (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOHN
Last Name:GUNNINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4116
Mailing Address - Country:US
Mailing Address - Phone:509-897-3000
Mailing Address - Fax:509-897-5898
Practice Address - Street 1:1025 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4116
Practice Address - Country:US
Practice Address - Phone:509-897-3000
Practice Address - Fax:509-897-5898
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026780207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2221GUOtherREGENCE
WA0242279OtherL & I
WA8949248OtherL& I CRIME VICTIMS
WA8602476Medicaid
B18281Medicare UPIN
WA8602476Medicaid
WA2221GUOtherREGENCE