Basic Information
| Provider Information | |||||||||
| NPI: | 1396999512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUBEDI | ||||||||
| FirstName: | SHREE | ||||||||
| MiddleName: | KRISHNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2537614201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | MD195622 | OR | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207U00000X | MD60993530 | WA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085R0202X | 57914 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0904X | MD60993530 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 13406 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | R3227 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD195622 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60993530 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2141551 | 05 | WA | MEDICAID | 0414632 | 01 | WA | L&I-DINW | OTHER | 0414629 | 01 | WA | L&I-TRA PIERCE | OTHER | 0414630 | 01 | WA | L&I-TRA KING | OTHER | 0414631 | 01 | WA | L&I-UAOM | OTHER |