Basic Information
| Provider Information | |||||||||
| NPI: | 1619086386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3007 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981143007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883616 | ||||||||
| FaxNumber: | 2066525216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 S OTHELLO ST | ||||||||
| Address2: | 2ND FL. | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981183510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883535 | ||||||||
| FaxNumber: | 2067883521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00034417 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1014656 | 05 | WA | MEDICAID | 8204653 | 05 | WA | MEDICAID |