Healthcare Provider Details

I. General information

NPI: 1700908019
Provider Name (Legal Business Name): EDWIN YAO-YUAN CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E KINCAID ST
MOUNT VERNON WA
98274-4127
US

IV. Provider business mailing address

1400 E KINCAID ST ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-2586
  • Fax: 360-428-6470
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD00049137
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberMD00049137
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberMD00049137
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD00049137
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: