Basic Information
| Provider Information | |||||||||
| NPI: | 1801010053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGARWAL | ||||||||
| FirstName: | ABHISHEK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 S MERIDIAN STE 305 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717590 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1703 S MERIDIAN | ||||||||
| Address2: | STE 305 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413933 | ||||||||
| FaxNumber: | 2538487970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD60647401 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | E5097 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G001045700 | 01 | WA | GROUP PTAN(P) | OTHER | MD60647401 | 01 | WA | WA LICENSE | OTHER | 2060137 | 05 | WA | MEDICAID | G000188100 | 01 | WA | GROUP PTAN(K) | OTHER |