Basic Information
| Provider Information | |||||||||
| NPI: | 1134177413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRIVEDI | ||||||||
| FirstName: | ASHISH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 125 3RD ST NE | ||||||||
| Address2: | STE 402 | ||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980024035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533331637 | ||||||||
| FaxNumber: | 2533518509 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 3RD ST NE STE 402 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980024035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533331637 | ||||||||
| FaxNumber: | 2533518509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00039851 | WA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1113588 | 05 | WA | MEDICAID |