Basic Information
Provider Information | |||||||||
NPI: | 1558354191 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TUNG | ||||||||
FirstName: | MILLIE | ||||||||
MiddleName: | Y | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD FACP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13684 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981981010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254538406 | ||||||||
FaxNumber: | 4254534173 | ||||||||
Practice Location | |||||||||
Address1: | 2015 116TH AVE NE | ||||||||
Address2: | SUITE B | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980043031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254538406 | ||||||||
FaxNumber: | 4254534173 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2005 | ||||||||
LastUpdateDate: | 12/14/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00014377 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | MD00014377 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 1520501 | 05 | WA |   | MEDICAID |