Healthcare Provider Details

I. General information

NPI: 1053340885
Provider Name (Legal Business Name): SHAISTA QUDDUSI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAISTA ANSARI MD

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S 320TH ST SUITE D
FEDERAL WAY WA
98003-4691
US

IV. Provider business mailing address

700 S 320TH ST, ADVANCED DIABETES & ENDOCRINE CARE SUITE D
FEDERAL WAY WA
98003
US

V. Phone/Fax

Practice location:
  • Phone: 253-880-1029
  • Fax:
Mailing address:
  • Phone: 253-880-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00032808
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD00032808
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: