Provider Demographics
NPI:1609058759
Name:SIDHU, DAMANJOT KAUR (ARNP)
Entity Type:Individual
Prefix:
First Name:DAMANJOT
Middle Name:KAUR
Last Name:SIDHU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:DAMAN
Other - Middle Name:
Other - Last Name:SANGHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-426-6341
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0226838OtherSTATE L&I
WA8499238Medicaid
WAG8869345Medicare PIN
WAG8869346Medicare PIN