Healthcare Provider Details

I. General information

NPI: 1659470516
Provider Name (Legal Business Name): MARY CHANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 16TH AVE E
SEATTLE WA
98112-5211
US

IV. Provider business mailing address

125 16TH AVE E
SEATTLE WA
98112-5211
US

V. Phone/Fax

Practice location:
  • Phone: 206-326-3000
  • Fax:
Mailing address:
  • Phone: 206-326-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60688813
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104555718
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: