Basic Information
| Provider Information | |||||||||
| NPI: | 1831290154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMMERMAN | ||||||||
| FirstName: | SETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1381 UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074335494 | ||||||||
| FaxNumber: | 7073852157 | ||||||||
| Practice Location | |||||||||
| Address1: | 1381 UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074335494 | ||||||||
| FaxNumber: | 7073852157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | G54409 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G544090 | 05 | CA | MEDICAID |