Healthcare Provider Details

I. General information

NPI: 1851313761
Provider Name (Legal Business Name): DOUGLAS R D'JANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 PORT OF TACOMA RD
TACOMA WA
98421-3707
US

IV. Provider business mailing address

1930 PORT OF TACOMA RD
TACOMA WA
98421-3707
US

V. Phone/Fax

Practice location:
  • Phone: 253-274-5521
  • Fax: 206-763-5241
Mailing address:
  • Phone: 253-274-5521
  • Fax: 206-763-5241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003479
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: