Provider Demographics
NPI:1457946212
Name:AMIRDZHANOV, ALEXANDER B
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:B
Last Name:AMIRDZHANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 S 168TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98188-3161
Mailing Address - Country:US
Mailing Address - Phone:206-235-0781
Mailing Address - Fax:
Practice Address - Street 1:4007 S 168TH ST
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98188-3161
Practice Address - Country:US
Practice Address - Phone:206-235-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC10871171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter