1619086386 NPI number — GRACE WANG MD

Table of content: GRACE WANG MD (NPI 1619086386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619086386 NPI number — GRACE WANG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANG
Provider First Name:
GRACE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619086386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98114-3007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-788-3616
Provider Business Mailing Address Fax Number:
206-652-5216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3815 S OTHELLO ST
Provider Second Line Business Practice Location Address:
2ND FL.
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98118-3510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-788-3535
Provider Business Practice Location Address Fax Number:
206-788-3521
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00034417 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1014656 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8204653 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com