Provider Demographics
NPI:1689798571
Name:OLIVETO, RYONG BAE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:RYONG
Middle Name:BAE
Last Name:OLIVETO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 ORCA DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-1999
Mailing Address - Country:US
Mailing Address - Phone:253-568-2435
Mailing Address - Fax:
Practice Address - Street 1:22727 HIGHWAY 99
Practice Address - Street 2:SUITE 205
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8381
Practice Address - Country:US
Practice Address - Phone:425-771-3164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00010027Medicare UPIN