Basic Information
| Provider Information | |||||||||
| NPI: | 1083661631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANTT | ||||||||
| FirstName: | SOREN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50010 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981051010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069878450 | ||||||||
| FaxNumber: | 2069878484 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069871909 | ||||||||
| FaxNumber: | 2069873890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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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 | 208000000X | MD00043059 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | MD00043059 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 8452617 | 05 | WA | MEDICAID | 807507400 | 05 | ID | MEDICAID |