Provider Demographics
NPI:1396043725
Name:LAN, ATHENA HONG (DO)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:HONG
Last Name:LAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:HONG CAM
Other - Last Name:VUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 34876
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1876
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60456156208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA333770OtherSTATE L&I
WA333773OtherSTATE L&I
WA333771OtherSTATE L&I
WA2038514Medicaid
WA333778OtherSTATE L&I
WA333776OtherSTATE L&I
WA333771OtherSTATE L&I
WAG8955713Medicare PIN
WA333770OtherSTATE L&I