Provider Demographics
NPI:1588718027
Name:MALIJAN, EDWIN TRIA (RPT)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:TRIA
Last Name:MALIJAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 19TH AVE SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3853
Mailing Address - Country:US
Mailing Address - Phone:425-379-8120
Mailing Address - Fax:425-338-1789
Practice Address - Street 1:9505 19TH AVE SE
Practice Address - Street 2:SUITE 101
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3853
Practice Address - Country:US
Practice Address - Phone:425-379-8120
Practice Address - Fax:425-338-1789
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2243189OtherAETNA HMO, QPOS ID#
WA7084650Medicaid
WA11362400OtherCIGNA&CAQH PROVIDER ID#
WA0115893OtherDEPT OF L&I PROVIDER ID#
WA7076062OtherAETNA PPO,POS,EPO ID#