Healthcare Provider Details

I. General information

NPI: 1376644351
Provider Name (Legal Business Name): EVANGELINE CUA GAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 BOTHELL-EVERETT HWY SUITE 190
EVERETT WA
98208-6644
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 425-316-5160
  • Fax: 425-225-1005
Mailing address:
  • Phone: 866-366-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00035936
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00035936
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: