Healthcare Provider Details

I. General information

NPI: 1609889062
Provider Name (Legal Business Name): PO-SHEN CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

IV. Provider business mailing address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-2400
  • Fax:
Mailing address:
  • Phone: 360-636-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00034489
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: