Healthcare Provider Details

I. General information

NPI: 1467959619
Provider Name (Legal Business Name): TAE YONG CHANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 01/19/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 SNELLING AVE S
SAINT PAUL MN
55116-1525
US

IV. Provider business mailing address

565 SNELLING AVE S
SAINT PAUL MN
55116-1525
US

V. Phone/Fax

Practice location:
  • Phone: 651-698-0386
  • Fax: 866-314-4031
Mailing address:
  • Phone: 651-698-0386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number78259
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: