Basic Information
| Provider Information | |||||||||
| NPI: | 1972681500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 6TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1112 6TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A90004 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD60884533 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 04-35538 | 01 | KS | MEDICAL LICENSE | OTHER | 2104499 | 05 | WA | MEDICAID |