Provider Demographics
NPI:1578004131
Name:CHANG, ETHAN (DO)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:7203 129TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98056-1412
Practice Address - Country:US
Practice Address - Phone:425-690-3455
Practice Address - Fax:425-690-9455
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAOP61311708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2160428Medicaid