Basic Information
| Provider Information | |||||||||
| NPI: | 1861462368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASHWORTH | ||||||||
| FirstName: | SIMEON | ||||||||
| MiddleName: | WESLEY | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11315 BRIDGEPORT WAY SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539851711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984313004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539683885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 08/23/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/08/2019 | ||||||||
| NPIReactivationDate: | 03/14/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OP00002255 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0226247 | 01 | WA | LIWA | OTHER | 0226248 | 01 | WA | LIWA | OTHER | 8497836 | 05 | WA | MEDICAID | 0226246 | 01 | WA | LIWA | OTHER | 5517AS | 01 | WA | BSWA | OTHER |