Provider Demographics
NPI:1295810133
Name:FANG, WAYNE SY (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:SY
Last Name:FANG
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46465 - 0202085R0202X
WAMD600828802085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0385162OtherL&I-SOUTH SOUND RADIOLOGY
WA0367299OtherL&I-SWEDISH RADIA EDMONDS
WA0367300OtherL&I-EVERGREEN RADIA
WA0367297OtherL&I-RADIA REST OF WA
WA0367298OtherL&I-RADIA KING COUNTY
WA2000900Medicaid
WAG8960183Medicare PIN