Basic Information
| Provider Information | |||||||||
| NPI: | 1396043725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAN | ||||||||
| FirstName: | ATHENA | ||||||||
| MiddleName: | HONG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VUONG | ||||||||
| OtherFirstName: | ATHENA | ||||||||
| OtherMiddleName: | HONG CAM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34876 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565412 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 S 43RD ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252283440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 02/24/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | OP60456156 | WA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | OP60456156 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 333770 | 01 | WA | STATE L&I | OTHER | 333773 | 01 | WA | STATE L&I | OTHER | 333771 | 01 | WA | STATE L&I | OTHER | 2038514 | 05 | WA | MEDICAID | 333778 | 01 | WA | STATE L&I | OTHER | 333776 | 01 | WA | STATE L&I | OTHER |