Healthcare Provider Details

I. General information

NPI: 1649899980
Provider Name (Legal Business Name): JASMINE SIDHU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 260
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

300 SINGLETON RIDGE ROAD
CONWAY SC
29526
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-6450
  • Fax: 360-514-6451
Mailing address:
  • Phone: 843-347-8134
  • Fax:

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61441710
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: