Healthcare Provider Details

I. General information

NPI: 1316930985
Provider Name (Legal Business Name): KHANH BAO HOANG DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CONNIE BAO HOANG DPM

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 NORTHRIDGE PL SE
LACEY WA
98503-7187
US

IV. Provider business mailing address

3901 NORTHRIDGE PL SE
LACEY WA
98503-7187
US

V. Phone/Fax

Practice location:
  • Phone: 360-402-1015
  • Fax:
Mailing address:
  • Phone: 360-402-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 00000794
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: