Provider Demographics
NPI:1013302520
Name:HA, JOHNATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:HA
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 1:11311 BRIDGEPORT WAY SW STE 207
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3051
Mailing Address - Country:US
Mailing Address - Phone:253-272-8664
Mailing Address - Fax:253-627-7880
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 207
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3051
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-627-7880
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61132712207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2180700Medicaid