Basic Information
| Provider Information | |||||||||
| NPI: | 1578540480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GO | ||||||||
| FirstName: | GRETA | ||||||||
| MiddleName: | TAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 2085P0229X | M-12399 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | MD00038515 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-12399 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | MD00038515 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 164154 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 204103 | 01 | WA | LNI PROVIDER ID | OTHER | 135883 | 01 | WA | LNI PROVIDER ID | OTHER | 139425 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8254997 | 05 | WA | MEDICAID | 1578540480 | 05 | ID | MEDICAID | 213704 | 01 | WA | LNI PROVIDER ID | OTHER |