Healthcare Provider Details

I. General information

NPI: 1154881175
Provider Name (Legal Business Name): ANTENEH K FISSEHA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
US

IV. Provider business mailing address

747 BROADWAY
SEATTLE WA
98122-4379
US

V. Phone/Fax

Practice location:
  • Phone: 62-152-5202
  • Fax: 206-386-3180
Mailing address:
  • Phone: 206-386-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61302801
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOP61302801
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02007470A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: