Provider Demographics
NPI:1073574471
Name:RATTANASAMPHAN, WORAWAN (MD)
Entity Type:Individual
Prefix:
First Name:WORAWAN
Middle Name:
Last Name:RATTANASAMPHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 112TH AVE, NE
Mailing Address - Street 2:SUITE A-101
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008
Mailing Address - Country:US
Mailing Address - Phone:425-688-5234
Mailing Address - Fax:425-688-5756
Practice Address - Street 1:1750 112TH AVE NE
Practice Address - Street 2:SUITE A-101
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3752
Practice Address - Country:US
Practice Address - Phone:425-688-5234
Practice Address - Fax:425-688-5756
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1073574471OtherNPI
WAMD00045055OtherLICENSE
WAMD00045055OtherLICENSE