Healthcare Provider Details

I. General information

NPI: 1750592887
Provider Name (Legal Business Name): SREEKANTH R AMBATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34515 9TH AVE S
FEDERAL WAY WA
98003-6761
US

IV. Provider business mailing address

34515 9TH AVE S
FEDERAL WAY WA
98003-6761
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT188471
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD440951
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61174497
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD61174497
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: