Healthcare Provider Details

I. General information

NPI: 1992311559
Provider Name (Legal Business Name): TAJU ALI AHMED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12738 SE 173RD PL
RENTON WA
98058-6034
US

IV. Provider business mailing address

12738 SE 173RD PL
RENTON WA
98058-6034
US

V. Phone/Fax

Practice location:
  • Phone: 206-409-8266
  • Fax:
Mailing address:
  • Phone: 206-409-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMA2525
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: