Provider Demographics
NPI:1639518327
Name:ANG, JESSY EDGARDO JR (MD)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:EDGARDO
Last Name:ANG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9537 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1513
Mailing Address - Country:US
Mailing Address - Phone:253-984-2000
Mailing Address - Fax:253-984-2049
Practice Address - Street 1:9537 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1513
Practice Address - Country:US
Practice Address - Phone:253-984-2000
Practice Address - Fax:253-984-2049
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD462471207Q00000X
WAMD60656540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2156819Medicaid
WA366472OtherSTATE L&I