Basic Information
| Provider Information | |||||||||
| NPI: | 1407992076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NG | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2067635241 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2067635241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 228746 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | C166443 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 26096 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD60750871 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2084482 | 05 | WA | MEDICAID |