Basic Information
| Provider Information | |||||||||
| NPI: | 1558564617 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VICHUGSANANON | ||||||||
| FirstName: | DEENA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 FREEWAY DR | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982735445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608146870 | ||||||||
| FaxNumber: | 3608146922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD60366262 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2028010 | 05 | WA | MEDICAID |