Provider Demographics
NPI:1942411533
Name:KANG, SUPRIYA A (MD)
Entity Type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:A
Last Name:KANG
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 1:5455 ALMIRA DR NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8331
Mailing Address - Country:US
Mailing Address - Phone:360-415-3932
Mailing Address - Fax:
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8331
Practice Address - Country:US
Practice Address - Phone:360-415-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000476102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1034868Medicaid
WAG8941711Medicare PIN