1598182990 NPI number — ANNIE KYUNGA AHN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598182990 NPI number — ANNIE KYUNGA AHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AHN
Provider First Name:
ANNIE
Provider Middle Name:
KYUNGA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598182990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 LIND AVE SW
Provider Second Line Business Mailing Address:
SUITE 100 ATTN CREDENTIALING
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98057-4970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-690-2715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4033 TALBOT RD S STE 540
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-690-3602
Provider Business Practice Location Address Fax Number:
425-690-9602
Provider Enumeration Date:
03/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  MD60943971 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2139652 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G9000068 . This is a "MEDICARE W VALLEY MEDICAL GROUP - RENTON" identifier . This identifiers is of the category "OTHER".




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