Provider Demographics
NPI:1104517564
Name:AHMADI, PEZHMAN
Entity type:Individual
Prefix:MR
First Name:PEZHMAN
Middle Name:
Last Name:AHMADI
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 1:1203 N 10TH PL APT 1323
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5467
Mailing Address - Country:US
Mailing Address - Phone:831-710-5987
Mailing Address - Fax:
Practice Address - Street 1:13030 MILITARY RD S FL 2
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-3085
Practice Address - Country:US
Practice Address - Phone:206-839-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPR61549434390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program