Provider Demographics
NPI:1578540480
Name:GO, GRETA TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GRETA
Middle Name:TAN
Last Name:GO
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-123992085P0229X, 2085R0202X
WAMD000385152085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA164154OtherL&I PROVIDER NUMBER
WA204103OtherLNI PROVIDER ID
WA135883OtherLNI PROVIDER ID
WA139425OtherL&I PROVIDER NUMBER
WA8254997Medicaid
ID1578540480Medicaid
WA213704OtherLNI PROVIDER ID
WAF93573Medicare UPIN
ID1578540480Medicaid
WAGAB34671Medicare PIN
WAGAB15063Medicare PIN
WAG8883987Medicare PIN
WA8869891Medicare PIN
WAGAB15062Medicare PIN
WAP00672393Medicare PIN
WAG8861619Medicare PIN
WA8254997Medicaid
ID20005724Medicare PIN