Provider Demographics
NPI:1033887443
Name:CHONG, TAYLOR KEIICHI (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:KEIICHI
Last Name:CHONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 N 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6907
Mailing Address - Country:US
Mailing Address - Phone:206-633-8100
Mailing Address - Fax:206-633-6107
Practice Address - Street 1:5350 TALLMAN AVE NW STE 500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5902
Practice Address - Country:US
Practice Address - Phone:206-784-8833
Practice Address - Fax:206-784-0676
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61407244363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2257812Medicaid