=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104037043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENSI SUN M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11231 ROOSEVELT WAY, NE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-365-5800
-----------------------------------------------------
Fax | 206-364-2072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11231 ROOSEVELT WAY NE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98125-6225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-365-5800
-----------------------------------------------------
Fax | 206-364-2072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | MD00039922
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------