Provider Demographics
NPI: | 1861462368 |
---|---|
Name: | ASHWORTH, SIMEON WESLEY (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | SIMEON |
Middle Name: | WESLEY |
Last Name: | ASHWORTH |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 11315 BRIDGEPORT WAY SW |
Mailing Address - Street 2: | |
Mailing Address - City: | LAKEWOOD |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98499-3004 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-985-1711 |
Mailing Address - Fax: | |
Practice Address - Street 1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE |
Practice Address - Street 2: | |
Practice Address - City: | TACOMA |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98431-3004 |
Practice Address - Country: | US |
Practice Address - Phone: | 253-968-3885 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-01-25 |
Last Update Date: | 2024-03-14 |
Deactivation Date: | 2019-02-08 |
Deactivation Code: | |
Reactivation Date: | 2019-03-14 |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | OP00002255 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 0226246 | Other | LIWA |
WA | 0226247 | Other | LIWA |
WA | 0226248 | Other | LIWA |
WA | 5517AS | Other | BSWA |
WA | 8497836 | Medicaid | |
WA | 0226247 | Other | LIWA |
WA | 5517AS | Other | BSWA |