Provider Demographics
NPI:1306341706
Name:POURGHADERI, POYA (DO)
Entity type:Individual
Prefix:
First Name:POYA
Middle Name:
Last Name:POURGHADERI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3124 S 19TH ST STE C320
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2485
Practice Address - Country:US
Practice Address - Phone:253-301-5100
Practice Address - Fax:253-301-5101
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61508886208C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program