Basic Information
| Provider Information | |||||||||
| NPI: | 1407321508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGO | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | NGHIEM | ||||||||
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| Credential: | OD | ||||||||
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| OtherLastName: | NGO | ||||||||
| OtherFirstName: | NGHIEM | ||||||||
| OtherMiddleName: | SY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2930 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982013832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
| FaxNumber: | 2535963301 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
| FaxNumber: | 2535963301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2018 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD60976602 | WA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.