Provider Demographics
NPI:1386835726
Name:BERGQUIST, AVANTI (MD)
Entity type:Individual
Prefix:
First Name:AVANTI
Middle Name:
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AVANTI
Other - Middle Name:
Other - Last Name:BARUAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2050
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-0050
Mailing Address - Country:US
Mailing Address - Phone:425-765-2012
Mailing Address - Fax:
Practice Address - Street 1:13925 INTERURBAN AVE S STE 120
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-5718
Practice Address - Country:US
Practice Address - Phone:206-948-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601081692084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry