Basic Information
| Provider Information | |||||||||
| NPI: | 1770601353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRA | ||||||||
| FirstName: | SROBONA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18625 NE 139TH ST | ||||||||
| Address2: | |||||||||
| City: | WOODINVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980726586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068497273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1806 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094524520 | ||||||||
| FaxNumber: | 5094525224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | ML20007916 | WA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD00049380 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.