Healthcare Provider Details

I. General information

NPI: 1104171974
Provider Name (Legal Business Name): KANWARDEEP KAUR SIDHU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 10TH ST NE STE 200
AUBURN WA
98002-4019
US

IV. Provider business mailing address

205 10TH ST NE STE 200
AUBURN WA
98002-4019
US

V. Phone/Fax

Practice location:
  • Phone: 253-351-5300
  • Fax: 253-351-5399
Mailing address:
  • Phone: 253-351-5300
  • Fax: 253-351-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60511455
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: