Provider Demographics
NPI:1124382668
Name:KANNEGANTI, PRAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:KANNEGANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34612 6TH AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8723
Mailing Address - Country:US
Mailing Address - Phone:253-838-8552
Mailing Address - Fax:253-272-0149
Practice Address - Street 1:34612 6TH AVE S STE 300
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8723
Practice Address - Country:US
Practice Address - Phone:253-838-8552
Practice Address - Fax:253-272-0149
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60819307207X00000X
IL125.069745207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2108169Medicaid