Healthcare Provider Details

I. General information

NPI: 1750711974
Provider Name (Legal Business Name): CHANG KI HONG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE
WASHINGTON DC
20017-2104
US

IV. Provider business mailing address

716 DIAMOND AVE
ALEXANDRIA VA
22301-1748
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-7000
  • Fax:
Mailing address:
  • Phone: 571-216-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001205378
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: