Basic Information
| Provider Information | |||||||||
| NPI: | 1639253313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHNADASAN | ||||||||
| FirstName: | BAHIRATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRISHNADASAN | ||||||||
| OtherFirstName: | BAIYA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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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 | 208G00000X | MD00041594 | WA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 8431710 | 05 | WA | MEDICAID |