Basic Information
| Provider Information | |||||||||
| NPI: | 1104947688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDDAIAH | ||||||||
| FirstName: | VANATHI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANAND | ||||||||
| OtherFirstName: | VANATHI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10452 SILVERDALE WAY NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603077300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10452 SILVERDALE WAY NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603077300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19951 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60096212 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00613195 | 01 | MS | RR MEDICARE | OTHER | 09331544 | 05 | MS | MEDICAID |