Basic Information
| Provider Information | |||||||||
| NPI: | 1396783940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONRAJ | ||||||||
| FirstName: | EDSON | ||||||||
| MiddleName: | GERRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 11315 BRIDGEPORT WAY SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535898700 | ||||||||
| FaxNumber: | 2535816588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00043988 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1186PO | 01 | WA | BSWA | OTHER | 8400749 | 05 | WA | MEDICAID | 0186779 | 01 | WA | LIWA | OTHER | 0186778 | 01 | WA | LIWA | OTHER | 2165PO | 01 | WA | BSWA | OTHER |