Basic Information
| Provider Information | |||||||||
| NPI: | 1639690563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIN | ||||||||
| FirstName: | SU | ||||||||
| MiddleName: | LEI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34503 9TH AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538358700 | ||||||||
| FaxNumber: | 2538358000 | ||||||||
| Practice Location | |||||||||
| Address1: | 34503 9TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538358700 | ||||||||
| FaxNumber: | 2538358000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD61091055 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2161950 | 05 | WA | MEDICAID |