Basic Information
| Provider Information | |||||||||
| NPI: | 1689839011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANG | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | DO | ||||||||
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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 DRIVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608146800 | ||||||||
| FaxNumber: | 3608146917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 02/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4633 | OK | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | OS11558 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | OP60606905 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | OP60606905 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 004858700 | 05 | FL | MEDICAID |