Healthcare Provider Details

I. General information

NPI: 1376731208
Provider Name (Legal Business Name): EUN JUNG YI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 NE 129TH ST
VANCOUVER WA
98686-3236
US

IV. Provider business mailing address

PO BOX 821350
VANCOUVER WA
98682-0030
US

V. Phone/Fax

Practice location:
  • Phone: 360-696-5022
  • Fax: 360-666-0466
Mailing address:
  • Phone: 360-696-5022
  • Fax: 360-666-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD153969
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD153969
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD60306086
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMED T 8395
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: