Provider Demographics
NPI:1104023688
Name:KIET, GRACE TANG (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:TANG
Last Name:KIET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 W 9TH ST APT 530
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1652
Mailing Address - Country:US
Mailing Address - Phone:518-253-2285
Mailing Address - Fax:
Practice Address - Street 1:401 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3715
Practice Address - Country:US
Practice Address - Phone:253-697-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97564207R00000X, 207RI0200X, 208000000X
WAMD61061146207RI0200X
NMMD2023-0276207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics