Provider Demographics
NPI:1639162456
Name:MONPONBANUA, AILEEN HIDALGO (MD)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:HIDALGO
Last Name:MONPONBANUA
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 1:601 S CARR RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5866
Mailing Address - Country:US
Mailing Address - Phone:425-227-3700
Mailing Address - Fax:425-227-3106
Practice Address - Street 1:601 S CARR RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5866
Practice Address - Country:US
Practice Address - Phone:425-227-3700
Practice Address - Fax:425-227-3106
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8370397Medicaid
WAH84021Medicare UPIN
WA8370397Medicaid