Provider Demographics
NPI:1518128339
Name:EDVALSON, TANUJA MARION (MD)
Entity Type:Individual
Prefix:
First Name:TANUJA
Middle Name:MARION
Last Name:EDVALSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 SE PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-9336
Mailing Address - Country:US
Mailing Address - Phone:509-690-2315
Mailing Address - Fax:509-459-0686
Practice Address - Street 1:1200 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3354
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60113335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60113335OtherMEDICAL LICENSE