Provider Demographics
NPI:1558008391
Name:SEYOUM, TIGIST EMIRU (AG ACNP)
Entity Type:Individual
Prefix:MRS
First Name:TIGIST
Middle Name:EMIRU
Last Name:SEYOUM
Suffix:
Gender:F
Credentials:AG ACNP
Other - Prefix:MRS
Other - First Name:TIGIST
Other - Middle Name:EMIRU
Other - Last Name:SEYOUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TIGIST SEYOUM
Mailing Address - Street 1:834 SW 361ST ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-7290
Mailing Address - Country:US
Mailing Address - Phone:206-859-7903
Mailing Address - Fax:
Practice Address - Street 1:834 SW 361ST ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-7290
Practice Address - Country:US
Practice Address - Phone:206-859-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61298660363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61298660Medicaid