Healthcare Provider Details

I. General information

NPI: 1760844708
Provider Name (Legal Business Name): KAMYAR VAZIRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9230 SKY ISLAND DR E FL 2
BONNEY LAKE WA
98391-7385
US

IV. Provider business mailing address

9230 SKY ISLAND DR E STE 101
BONNEY LAKE WA
98391-7385
US

V. Phone/Fax

Practice location:
  • Phone: 253-750-6110
  • Fax:
Mailing address:
  • Phone: 253-750-6110
  • Fax: 253-922-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60886183
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: