Provider Demographics
NPI:1710636899
Name:HAN, CHONG SUP (MD)
Entity type:Individual
Prefix:
First Name:CHONG
Middle Name:SUP
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:HAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1230 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3166
Mailing Address - Country:US
Mailing Address - Phone:800-813-2000
Mailing Address - Fax:
Practice Address - Street 1:1230 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3166
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD225697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program