Provider Demographics
NPI:1184620759
Name:ANG, ELLEN T (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:T
Last Name:ANG
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:PO BOX 6128
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-0128
Mailing Address - Country:US
Mailing Address - Phone:509-737-1880
Mailing Address - Fax:509-737-1879
Practice Address - Street 1:521 N YOUNG ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-585-5222
Practice Address - Fax:509-585-5271
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1184620759Medicaid
I17190Medicare UPIN
WAG8867043Medicare PIN