Provider Demographics
NPI:1578024519
Name:CHONG, STACEY GUO
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:GUO
Last Name:CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 NE 87TH AVE STE 460
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1965
Mailing Address - Country:US
Mailing Address - Phone:360-514-2340
Mailing Address - Fax:
Practice Address - Street 1:8821 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-514-2340
Practice Address - Fax:360-514-2345
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-30
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61483707207RR0500X
CAA176604207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program