Provider Demographics
NPI:1053499608
Name:WANG, KATHY I-WEN (DO)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:I-WEN
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:I-WEN
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 84125
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5425
Mailing Address - Country:US
Mailing Address - Phone:253-841-8939
Mailing Address - Fax:253-841-5944
Practice Address - Street 1:1519 3RD ST SE STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3742
Practice Address - Country:US
Practice Address - Phone:253-841-8939
Practice Address - Fax:253-841-5944
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002056207LP2900X, 208VP0014X
CA20A9456207LP2900X
MA220817207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8859223Medicare PIN