Provider Demographics
NPI:1912083635
Name:CHANG, TINA ANN
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ANN
Last Name:CHANG
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 1:1100 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-341-0860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110196643OtherRAIL ROAD MEDICARE
WA8246472Medicaid
WAP01030991OtherMEDICARE RAILROAD
WA1912083635Medicaid
4566OtherINTERNAL ID-MOTOR VEHICLE ID
WAMD0735WOtherALASKA MEDICAID
WA8919051Medicare PIN
WA110196643OtherRAIL ROAD MEDICARE
WAP01030991OtherMEDICARE RAILROAD
WA1912083635Medicaid
WA8902218Medicare PIN