Healthcare Provider Details

I. General information

NPI: 1790729283
Provider Name (Legal Business Name): SHI-YUAN CHENG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18525 101ST AVE NE STE. 3
BOTHELL WA
98011-3452
US

IV. Provider business mailing address

305 236TH PL SW
BOTHELL WA
98021-8689
US

V. Phone/Fax

Practice location:
  • Phone: 425-806-1943
  • Fax: 425-402-3900
Mailing address:
  • Phone: 425-483-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO00000736
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1121219
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: