Basic Information
| Provider Information | |||||||||
| NPI: | 1013302520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HA | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11311 BRIDGEPORT WAY SW STE 207 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2536277880 | ||||||||
| Practice Location | |||||||||
| Address1: | 11311 BRIDGEPORT WAY SW STE 207 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2536277880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2015 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD61132712 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2180700 | 05 | WA | MEDICAID |