Basic Information
Provider Information | |||||||||
NPI: | 1609958586 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NG | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | WYHAM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NG | ||||||||
OtherFirstName: | WYHAM | ||||||||
OtherMiddleName: | JOSEPH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 611 12TH AVE S | ||||||||
Address2: | STE 200 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981441911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063249360 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 611 12TH AVE S STE 200 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981441911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063249360 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | P000000319 | WA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 1297506 | 05 | WA |   | MEDICAID | 71502 | 01 | WA | L & I | OTHER | NG0036 | 01 |   | REGENCE | OTHER |