Provider Demographics
NPI:1174550669
Name:JIANG, SHAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHAN
Middle Name:
Last Name:JIANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SW 41ST ST STE J
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4974
Mailing Address - Country:US
Mailing Address - Phone:425-251-6650
Mailing Address - Fax:425-251-6654
Practice Address - Street 1:101 SW 41ST ST STE J
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4974
Practice Address - Country:US
Practice Address - Phone:425-251-6650
Practice Address - Fax:425-251-6654
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAI24068Medicare UPIN
WA8864056Medicare PIN