Healthcare Provider Details

I. General information

NPI: 1033887443
Provider Name (Legal Business Name): TAYLOR KEIICHI CHONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 TALLMAN AVE NW STE 500
SEATTLE WA
98107-5902
US

IV. Provider business mailing address

2409 N 45TH ST
SEATTLE WA
98103-6907
US

V. Phone/Fax

Practice location:
  • Phone: 206-784-8833
  • Fax: 206-784-0676
Mailing address:
  • Phone: 206-633-8100
  • Fax: 206-633-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA61407244
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: