Provider Demographics
NPI:1770102329
Name:KONG, CAROLIN SACHIKO
Entity type:Individual
Prefix:
First Name:CAROLIN
Middle Name:SACHIKO
Last Name:KONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15780 SW STRATFORD LOOP
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-5558
Mailing Address - Country:US
Mailing Address - Phone:562-756-8711
Mailing Address - Fax:
Practice Address - Street 1:2913 5TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6748
Practice Address - Country:US
Practice Address - Phone:855-255-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27371363LF0000X, 363LF0000X
OR202002630NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily