Basic Information
| Provider Information | |||||||||
| NPI: | 1831244839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRBACHEH | ||||||||
| FirstName: | MANSOUR | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 YAKIMA AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535916739 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 YAKIMA AVE | ||||||||
| Address2: | STE 115 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536820925 | ||||||||
| FaxNumber: | 2536820927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | MD00041506 | WA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1045856 | 05 | WA | MEDICAID |