Provider Demographics
NPI:1376644351
Name:GAN, EVANGELINE CUA (MD)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:CUA
Last Name:GAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL-EVERETT HWY
Practice Address - Street 2:SUITE 190
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6644
Practice Address - Country:US
Practice Address - Phone:425-316-5160
Practice Address - Fax:425-225-1005
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00035936208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8231037Medicaid
WAGAB37013Medicare PIN
WAG74756Medicare UPIN
WAG8878261Medicare PIN