Provider Demographics
NPI:1881665099
Name:SHIN, SE JUNG (MD)
Entity Type:Individual
Prefix:
First Name:SE JUNG
Middle Name:
Last Name:SHIN
Suffix:
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 1:3600 LIND AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4934
Mailing Address - Country:US
Mailing Address - Phone:425-228-3440
Mailing Address - Fax:
Practice Address - Street 1:10555 SE CARR RD BLDG M
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5820
Practice Address - Country:US
Practice Address - Phone:425-656-4270
Practice Address - Fax:425-656-4271
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22180207P00000X
WAMD00038373207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130308Medicaid
WAG8959946OtherMEDICARE
WA2065309Medicaid